Uworld Mental Health Nursing Test Questions and Answers (Verified 2021)

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Mental Health Nursing Test Id: 52191858 Question Id: 32261 (729561) A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end f... irst. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? Unordered Options Ordered Response 1. Expressive speech, vision 2. Light touch, hearing 3. Sense of position, graphesthesia 4. Weber tuning fork test, cranial nerve I Explanation Coup-contrecoup injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing contusions (bruising) of brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup). As the body bounces back, the brain strikes the opposing side of the skull (contrecoup). When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup). Executive function, memory, speech (Broca area), and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lobe, where vision is processed. (Option 2) The temporal lobe (lateral aspect of the brain) controls hearing and integrates sensory data (eg, auditory, visual, somatic). The Wernicke speech area in the temporal lobe is responsible for language comprehension. Light touch is processed by the sensory cortex in the parietal lobe. (Option 3) An interruption of sensory function indicates injury to either the spinal column or the parietal lobe. These injuries affect proprioception (awareness of body positioning) and graphesthesia (ability to identify writing on the skin, by touch). (Option 4) The Weber test screens for conductive hearing loss by checking whether a tuning fork held along the midline of the head is heard evenly in both ears. Cranial nerve I is the olfactory nerve. Hearing and smell are both processed by the temporal lobe. Educational objective: Coup-contrecoup injuries usually affect the frontal and occipital lobes. The frontal lobe controls executive function, memory, speech, and motor skills. The occipital lobe processes vision. Test Id: 52191858 Question Id: 31967 (729561) The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment? Unordered Options Ordered Response 1. Confusion and a learning disability 2. Delayed physical and emotional development 3. Disorientation and cognitive impairment 4. Low self-esteem and impaired social skills You answered this question correctly. Explanation The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: • Poor self-esteem • Increased risk for depression and anxiety • Increased risk for substance abuse • Academic or work failure • Trouble interacting with peers and adults (Option 1) Children with ADHD are more likely to have a learning disability. Confusion is not a typical clinical finding. (Option 2) Although children with ADHD may appear to be emotionally immature for their age, ADHD is not associated with delayed physical growth. (Option 3) Children with ADHD are not disoriented. ADHD is associated with a range of cognitive impairments, but no single cognitive dysfunction typifies all children with the disorder. Some children have no impairment at all. Educational objective: The diagnosis of ADHD includes the presence of hyperactivity, impulsiveness, and inattention. The negative consequences of the core manifestations include impaired social skills, poor self-esteem, academic or work failure, increased risk for depression and anxiety, and increased risk for substance abuse. Test Id: 52191858 Question Id: 31965 (729561) The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an intervention? Unordered Options Ordered Response 1. "I should offer a choice between 2 things for my child's clothes or meals." 2. "I will need to advocate for an individualized educational plan for my child." 3. "My child will outgrow this disorder around age 20." 4. "When talking with my child, I should not be multi-tasking." Explanation Symptoms of ADHD usually continue into adulthood; current research indicates that children do not outgrow the condition. However, individuals with ADHD learn to cope with and manage the symptoms and achieve their full potential, leading healthy and satisfying lives. They may move into a condition of being "recovered," but this is usually a dynamic and ongoing state. (Option 1) Children with ADHD are usually overwhelmed and overstimulated when faced with numerous choices. Offering 2 choices will help organize and structure the child's decision-making process. (Option 2) There are legal mandates requiring school-based services and accommodations for children with ADHD. However, some teachers and/or school systems may not be as familiar with these requirements; it is important that parents of children with ADHD advocate for these individualized services. (Option 4) Parents and caregivers should make direct eye contact and focus on their children when giving instructions. Other distractions should be minimized to avoid overstimulation. Educational objective: Two common misunderstandings about ADHD are that children outgrow it as they become adults, and that dietary modifications (eg, restricting additives and/or sugar) will improve or "cure" the symptoms. Neither statement is true. These individuals learn to cope with and manage their symptoms as they grow older, but they do not outgrow ADHD. Test Id: 52191858 Question Id: 31980 (729561) The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? Unordered Options Ordered Response 1. Compensation 2. Displacement 3. Projection 4. Reaction formation Explanation Displacement, one of many ego defense mechanisms, occurs when a person shifts uncomfortable feelings or impulses about one situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or impulses. (Option 1) Compensation involves experiencing a perceived deficit in one area and making up for it by overachieving in another. An example is someone not doing well academically who focuses on doing well in sports. (Option 3) Projection involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. An example is a husband with thoughts of infidelity who then accuses his wife of being unfaithful. (Option 4) Reaction formation involves transforming an unacceptable feeling or impulse into its opposite. An example is a client with cancer who fears dying but behaves in an overly optimistic and fearless manner about his treatment and prognosis. Educational objective: Displacement is an ego defense mechanism that involves transferring uncomfortable feelings, emotions, or impulses about one person or situation to a substitute person or situation. Copyright © UWorld. Test Id: 52191858 Question Id: 30748 (729561) Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply. Unordered Options Ordered Response 1. Assign the client to a private room 2. Choose clothing for the client 3. Have the client be in charge of planning an outing for the unit 4. Have the client join other clients in the dining room for meals 5. Have the client participate in physical exercise with a staff member 6. Include the client in group therapy sessions Explanation In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is characterized by the following: • Excessive psychomotor activity • Euphoric mood • Poor impulse control • Flight of ideas, non-stop talking • Poor attention span, distractibility • Hallucinations and delusions • Insomnia • Wearing bizarre or inappropriate clothing, jewelry, and makeup • Neglected hygiene and inadequate nutritional intake The care plan for a client experiencing an acute manic episode includes the following: • Reduction of environmental stimuli o Providing a quiet, calm environment o Limiting the number of people who come in contact with the client o One-on-one interactions rather than group activities o Low lighting • A structured schedule of activities to help the client stay focused • Physical activities to help relieve excess energy • Providing high-protein, high-calorie meals and snacks that are easy to eat • Setting limits on behavior (Option 3) The client is easily distractible and would not be able to focus on planning an activity. (Option 4) The client who is experiencing an acute manic episode needs reduced environmental stimuli. Eating with other clients in the dining room would be too stimulating and could exacerbate psychomotor activity. (Option 6) The client with acute mania is not ready to participate in group activities. Educational objective: The nursing care plan for clients with acute mania includes providing a quiet, structured, non-stimulating environment; engaging the client in one-on-one activities and physical activity; limiting contact with other people; and providing foods of high nutritional value that are easy to eat. Test Id: 52191858 Question Id: 33456 (729561) The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? Unordered Options Ordered Response 1. Fears abandonment, agreeable, needs constant reassurance 2. Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration 3. Seems uncomfortable around people, lack of close friends, indifferent to praise or criticism 4. Tries to intimidate others, manipulative, lacks empathy Explanation The nurse should recognize the following characteristics associated with histrionic personality disorder: • Self-dramatizing, exaggerated or shallow emotional expression • Attention-seeking, needs to be the center of attention • Overly friendly and seductive, attempts to keep others engaged • Demands immediate gratification and has little tolerance for frustration An individual with histrionic personality disorder displays these behaviors and characteristics persistently. The signs and symptoms are maladaptive and have a negative impact on the client's social, interpersonal, and occupational life. (Option 1) Clients with dependent personality disorder fear separation and tend to be indecisive and unable to take the initiative. They are often preoccupied with the thought of being left to fend for themselves and want others to assume responsibility for all major decision making. (Option 3) Clients with schizoid personality disorder exhibit social detachment and an inability to express emotion. They do not enjoy close relationships and prefer to be aloof and isolated. (Option 4) Clients with antisocial personality disorder have a pattern of disregard for and violation of the rights of others. They manipulate others for personal gain and lack empathy. Educational objective: Histrionic personality disorder is characterized by persistent attention-seeking behavior and exaggerated emotionality. The client with this disorder demands immediate gratification and has little tolerance for frustration. Test Id: 52191858 Question Id: 30686 (729561) The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the best priority response by the nurse? Unordered Options Ordered Response 1. "Do you have any friends in the building?" 2. "Have you had any thoughts of hurting yourself?" 3. "Tell me more about how you're feeling." 4. "You're not thinking of killing yourself, are you?" Explanation Giving away possessions and making statements such as, "There is no reason for me to go on," are indications of suicidal ideation. The most important nursing action is to perform a suicide risk assessment to determine interventions to ensure the client's safety. Determining if the client has had thoughts of self harm is a priority. The nurse can ask the client direct questions such as, "Do you feel like hurting yourself?" or "Are you thinking about killing yourself?" or "Do you want to die?" During the assessment, it is important for the nurse to create a sense of trust and compassion and engage the client in a nonjudgmental manner. Additional questions that are part of a suicide risk assessment include the following: • Have you thought about how you would kill yourself? • Do you have a plan to kill yourself? • If you were to kill yourself, how would you do it? If the client has a suicide plan, the nurse needs to ask about the details. The risk of a client completing suicide increases when the client has planned for a specific time and place, has chosen a highly lethal method (eg, firearm, hanging), and has chosen circumstances in which there would be little or no chance of interruption. (Option 1) It is important to assess the client's social support system, but it is not the priority assessment. (Option 3) This is not the priority assessment; it is more important to determine if the client is thinking about suicide or has a plan. (Option 4) This is a leading question and implies what the answer should be. Educational objective: A suicide risk assessment is the priority nursing action for a client who expresses thoughts about "not wanting to go on" or "wishing for death" or engages in potential suicidal indicators such as giving away possessions. Asking the client directly about thoughts of hurting or killing oneself is a therapeutic approach and an essential component of the risk assessment. Test Id: 52191858 Question Id: 30536 (729561) A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today…they are so angry with me." Which of the following is the best response by the nurse? Unordered Options Ordered Response 1. "Do you need something to help you calm down?" 2. "Don't pay any attention to the voices. Let's go into the dayroom." 3. "The voices are not real. Tell them to go away." 4. "What are the voices saying to you?" Explanation The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following: • Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) • Not arguing with or challenging the client about the hallucinations • Directing the client to a reality-oriented topic of conversation or activity (Option 1) An antianxiety medication may be needed if the voices are causing this client to become increasingly distressed. Assessment is needed before choosing this option. (Option 2) This choice dismisses this client's concerns about the nature of the voices. (Option 3) Telling the voices to "go away" (voice dismissal) is a technique that some clients find effective in management of hallucinations. It is not the priority nursing action in this client. Educational objective: It is important for the nurse to initially explore the content of a client's hallucinations to assess the risk for harm and/or injury and determine appropriate interventions. The nurse can tell the client that the nurse knows the voices are real to the client but are not heard by the nurse. The client with hallucinations should be directed to reality-oriented activities rather than to further discussion of the content of the hallucinations. Test Id: 52191858 Question Id: 30793 (729561) A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the best action by the nurse? Unordered Options Ordered Response 1. Have the client keep a journal and write about feelings 2. Initiate one-on-one supervision of the client during feedings 3. Remind the client that gaining weight means being able to go home 4. Say that the client is not fat and ugly Explanation Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for medical complications from anorexia nervosa, including death. Criteria for nutrition support include: • Severe weight loss that is life threatening • Client's unwillingness to adhere to a treatment plan of oral feedings The priority nursing actions for this high-risk client include interventions to meet physiological and safety needs. Providing one-on-one supervision during the tube feeding will ensure that the client is actually receiving the feeding and prevent the client from stopping the feeding and/or pulling out the nasogastric tube. During the one-on-one contact with the client, the nurse can promote a therapeutic and trusting relationship with the client by: • Being honest and accepting of the client • Presenting the reality of the condition • Acknowledging the client's feelings of loss of control and anger • Encouraging the client to express feelings and fears (Option 1) This is an appropriate intervention for a client with anorexia nervosa. Feelings related to lack of control are an underlying problem for these clients, who use food as a way to deal with them. Keeping a diary or journal of feelings will help the client recognize and express them more clearly. However, this is not the priority nursing action. (Option 3) This may be a true statement; clients with anorexia nervosa are usually discharged to out-patient follow-up and treatment or to a residential treatment facility once an acceptable weight gain has been achieved and maintained. However, this is not the priority nursing action. (Option 4) Clients with anorexia nervosa have a distorted body image and a morbid fear of being overweight; they perceive themselves as "fat and ugly" even when they are emaciated. Saying that the client is not "fat and ugly" will not change this perception. Educational objective: The priority nursing care for a client with anorexia nervosa is nutritional rehabilitation and prevention of medical complications, including death. Clients who are severely ill and/or resistant to oral refeeding may require nutrition support with intense monitoring to achieve adequate caloric intake and weight gain. Test Id: 52191858 Question Id: 30682 (729561) A client with major depressive disorder has been hospitalized for 3 days. The night nurse reports that the client has been unable to go to sleep until late at night. The client gets up, paces the hallway, wrings her hands, and appears teary. Which interventions should be included in the client's nursing care plan? Select all that apply. Unordered Options Ordered Response 1. Arrange for the client to receive 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Serve the client a glass of warm milk in the evening 5. Spend time with the client in a quiet environment just before bedtime 6. Tell the client to take a warm bath before going to bed Explanation Sleep disturbances are part of the diagnostic criteria for major depressive disorder. Clients may experience insomnia (early in the night, in the middle of the night, or in the early morning hours) or hypersomnia. A number of pharmacological agents are used to treat insomnia; however, long-term treatment with medication alone is not necessarily the best approach. Strategies for improving sleep hygiene include the following: • Staying up during the day and avoiding naps • Engaging in physical activity or exercise during the day, preferably at least 5 hours before bedtime • Receiving at least 20 minutes of natural sunlight each day, ideally in the morning (natural sunlight is associated with improved sleep patterns) • Avoiding coffee or other caffeinated beverages after noon • Avoiding alcohol and/or smoking at bedtime • Dealing with or thinking about one's concerns or issues prior to bedtime, letting go of one's worries before going to bed • Participating in a relaxing activity, such as a warm bath, reading, or listening to soft music, prior to bedtime • Decreasing environmental stimuli in the bedroom; making sure the room is dark, cool, and quiet • Avoiding heavy meals or large amounts of fluids at bedtime • Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime (milk contains tryptophan, which promotes sleepiness; carbohydrates aid in the release of serotonin, which promotes relaxation) (Option 2) Napping during the day interferes with normal sleep patterns. (Option 3) Exercising right before going to bed increases brain metabolic activity and wakefulness. Educational objective: Nonpharmacological strategies for improving sleep hygiene include exercising during the day, engaging in a relaxing activity before bedtime, dealing with worries at a set time of the day, providing a relaxing sleep environment, avoiding naps during the day, avoiding caffeine after noon, and drinking a warm cup of milk before bedtime. Test Id: 52191858 Question Id: 30571 (729561) The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse? Unordered Options Ordered Response 1. "I know you are frightened, but I do not see a man in your room." 2. "I'll make the bad man go away." 3. "Let's go into the dayroom and play checkers." 4. "Your illness is making you hallucinate." Explanation An important step toward self-management of hallucinations is for the client to recognize that the hallucinations are not real. When a client is experiencing hallucinations, the nurse needs to reinforce reality and acknowledge how the client may be feeling. The nurse can point out his/her own perceptions without denying the client's experience. It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a man get into your room? This is a locked hospital unit." Examples of additional therapeutic responses to a client who is experiencing hallucinations include the following: • "I don't see anything, but I understand that what you are seeing may be very upsetting to you." • "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real." • "I know the voices seem real to you and may be scary. I do not hear the voices." (Option 2) This response reinforces the hallucination and does not present reality to the client. (Option 3) This response ignores what the client is experiencing and does nothing to reduce the client's feeling of discomfort. (Option 4) This response provides an explanation for the client's experience but does not acknowledge the client's feelings or reinforce reality. Educational objective: The most therapeutic response to a client experiencing hallucinations presents reality and acknowledges how the client may be feeling. This approach promotes self- management by helping the client recognize that the hallucinations are not real. Test Id: 52191858 Question Id: 30922 (729561) A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply. Unordered Options Ordered Response 1. Desensitization to a specific stimulus or situation 2. Discussing the interpersonal difficulties that have led to the client's psychological problems 3. Helping the client develop insight into the psychological causes of the disorder 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking Explanation Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking. These types of disorders are characterized by maladaptive reactions to stress, anxiety, and conflict. CBT requires that the client learn the skill of self- observation and to apply more adaptive coping interventions. CBT involves 5 basic components: • Education about the client's specific disorder • Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity • Physical control strategies – deep breathing and muscle relaxation exercises • Cognitive restructuring – learning new ways to reframe thinking patterns, challenging negative thoughts • Behavioral strategies – focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events (Option 2) This describes interpersonal psychotherapy. (Option 3) This describes psychodynamic or psychoanalytic therapy. Educational objective: CBT teaches clients to reframe their thought processes and develop new adaptive approaches for coping with anxiety, stress, and conflict. CBT requires that the client learn about the disorder and engage in self-observation and monitoring, relaxation techniques, desensitization activities, and changing negative thoughts. Test Id: 52191858 Question Id: 33434 (729561) The nurse assesses a client who is suspected of using illicit substances. Which assessment findings would indicate heroin withdrawal? Select all that apply. Unordered Options Ordered Response 1. Bone and muscle pains 2. Bradycardia 3. Dilated pupils 4. Drowsiness 5. Rhinorrhea Explanation When a person has used a substance heavily for a long time and it is stopped or reduced, a set of physiological symptoms occurs as the amount of the substance in the system decreases. Heroin is a commonly abused opioid drug. Generalized myalgias, abdominal cramps, diarrhea, piloerection (goose bumps), and pupillary dilation are consistent with opioid withdrawal. Other common features include nausea, vomiting, frequent yawning, restlessness, rhinorrhea, and increased lacrimation. (Options 2 and 4) The heart rate would be rapid and the client would have insomnia and anxiety. Mental status may be impaired in acute opioid intoxication but is usually normal in withdrawal. Educational objective: Manifestations of heroin withdrawal include myalgias, arthralgias, abdominal cramps, diarrhea, piloerection (goose bumps), and pupillary dilation. Frequent yawning, restlessness, rhinorrhea, and increased lacrimation are also common. Test Id: 52180127 Question Id: 30300 (729561) Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques? Unordered Options Ordered Response 1. "I don't understand what you mean. Can you give me an example?" 2. "It is doubtful the president is out to get you." 3. "Tell me more about the day your child died." 4. "Why did you get so angry when she ignored you?" Explanation Therapeutic communication allows the nurse to develop a healthy interpersonal relationship with the client. A "why" question is often avoided as it is viewed negatively by clients and can make them feel defensive about their choices or emotions (Option 4). (Option 1) Asking for an example is asking for clarification and is considered a therapeutic communication technique. (Option 2) Voicing doubt is a therapeutic communication technique that allows the nurse to dispel misconceptions or delusions without directly confronting the client's beliefs. (Option 3) Exploring is a therapeutic communication technique that encourages the client to discuss relevant situations and feelings. If the client chooses not to share information, the nurse should respect that decision and not probe further. Educational objective: For people who are anxious or overwhelmed, a "why" question asked by the nurse is often interpreted as being critical, judgmental, and intrusive. These feelings are damaging to the development of the nurse-client relationship and therapeutic communication. Test Id: 52180127 Question Id: 31289 (729561) The client had surgery for possible cancer. The positive biopsy result is back in the medical record, but the client has not been told that the biopsy showed malignancy. The client asks the nurse, "Am I going to die?" What is the best way for the nurse to initially handle the situation? Unordered Options Ordered Response 1. "Everyone will die one day, but good treatment is available for most cancers today." 2. "I can understand your anxiety about the situation. Let me call your health care provider (HCP)." 3. "Share with me your thoughts and feelings about the situation." 4. "The biopsy result came back as malignant, but that doesn't mean the cancer is not treatable." Explanation The nurse must first assess the client's knowledge and feelings about the situation. Use of therapeutic communication techniques, including listening, reflection, and focusing allow the nurse to determine the client's needs at that time. Often, the client is just seeking an empathetic listener. (Option 1) Under the ethical principle of veracity, the nurse should not lie or offer false reassurance. It is unclear at this time what the prognosis or treatment options are for this client, and automatic responses (eg, "everyone will die one day") and false reassurance (eg, "good treatment is available for most cancers today") are types of nontherapeutic communication. (Option 2) Although contacting the HCP may be necessary, the nurse should first explore the client's thoughts and feelings to determine the client's current needs. (Option 4) The news of the positive biopsy result should be given by the HCP so that factual information as well as prognosis and treatment options can be provided at that time. There is no ethical or legal obligation for the nurse to reveal a client's results the moment the results are available. Educational objective: When asked by a client about results or dying, respond by assessing the client's understanding of the situation and/or feelings about the topic using therapeutic communication skills. Test Id: 52180127 Question Id: 33469 (729561) The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first? Unordered Options Ordered Response 1. Auscultate lung sounds bilaterally 2. Hyper-oxygenate with 100% oxygen 3. Manually ventilate with bag valve mask 4. Suction the endotracheal tube Explanation A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not uncommon for the tube to become displaced in the hypopharynx, which would not allow proper ventilation. Another important complication is pneumothorax, which can cause hypotension and a drop in oxygen saturation. Lung auscultation would help diagnose this as well. (Option 2) Hyper-oxygenating would not increase ventilation if the tube is not in proper position or if the client has a pneumothorax. (Option 3) The first step is to confirm tube placement. Manually ventilating through a displaced tube would produce no better results than use of the ventilator. (Option 4) Mucus plugs are a common cause of decreased oxygen saturation in the intubated client. There are, however, specific symptoms associated with this problem, including secretions backing up in the tube and high-pressure ventilator alarms. Although this client may still need suctioning even if these symptoms are not present, auscultating lung sounds is necessary to confirm tube placement before suctioning. Suctioning via a displaced tube could cause additional damage to the client's airway. Educational objective: Proper placement of the endotracheal tube is essential for adequate ventilation in intubated clients. If the tube becomes displaced in the hypopharynx, hypoxemia can result. Confirming the presence of equal breath sounds bilaterally via auscultation is an important initial nursing intervention. Test Id: 52138759 Question Id: 30795 (729561) A client hospitalized for anorexia nervosa has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which nursing actions are appropriate for promoting weight gain in this client? Select all that apply. Unordered Options Ordered Response 1. Determine minimum goals for daily caloric intake and weekly weight gain 2. Do not allow client to make food choices 3. Restrict privileges if weight loss occurs 4. Reweigh client on request 5. Set limits on physical activities 6. Sit with client during meals and discuss nutritional value of served foods Explanation Clients who need hospitalization for anorexia nervosa will commonly have protein- energy malnutrition and severe weight loss within a short period. Weight gain and improvement in nutritional intake must be achieved before the client can be discharged to outpatient follow-up and treatment. Nursing care strategies for promoting intake and weight gain include: • Determining minimal caloric intake for weight gain and keeping a daily record of consumed calories and protein o If the client is unable to consume adequate oral nutrition, tube feedings may be necessary • Establishing a goal for weekly weight gain o Weight gain of 2-3 lb (0.9-1.36 kg/wk) is an appropriate goal for most clients; anything higher would place the client at risk for re-feeding syndrome due to excessive caloric intake. o Clients should initially be weighed daily in the morning, at the same time, on the same scale, in the same clothing, after voiding and before meals o The frequency of weigh-ins can be reduced once the client has established a pattern of adherence to the treatment plan, as evidenced by weight gain o Weigh-ins should be done in a matter-of-fact, non-judgmental manner • Allowing clients to make food choices when possible to give a sense of control o Low-calorie food selections must be monitored and limited • One-on-one supervision during meals to ensure the client consumes food and does not pocket it or throw it away; discussions about food should be limited to minimize the client's preoccupation with food. • Allowing privileges only if the client adheres to the treatment plan, as evidenced by weight gain o Setting limits avoids power struggles, provides structure, and ensures client safety • Monitoring and setting limits on physical activity (Option 2) Clients should be allowed to make food choices when feasible. (Option 4) Reweighing on request will reinforce the client's preoccupation with weight. (Option 6) Discussing the nutritional value of foods will reinforce the client's preoccupation with food. Educational objective: Strategies to improve nutritional intake and promote weight gain in a client with anorexia nervosa include setting goals for daily caloric intake and weekly weight gain, allowing the client to make food choices, monitoring intake, setting limits on physical activity and exercise, basing privileges on treatment adherence, and maintaining a matter-of-fact, nonjudgmental approach toward weight and food-related behaviors. Test Id: 52138759 Question Id: 30217 (729561) A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium? Unordered Options Ordered Response 1. 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3. 60-year-old client with type II diabetes, 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis Explanation Major predisposing factors for the development of delirium in hospitalized clients include: 1. Advanced age 2. Underlying neurodegenerative disease (stroke, dementia) 3. Polypharmacy 4. Coexisting medical conditions (eg, infection) 5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) 6. Metabolic and electrolyte disturbances 7. Impaired mobility - early ambulation prevents delirium 8. Surgery (postoperative setting) 9. Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. (Option 1) Although gastroenteritis with possible dehydration and electrolyte imbalances predisposes to delirium, this client is not at greatest risk. (Option 2) Although surgery, especially that requiring cardiac bypass, predisposes to delirium, this client is not at greatest risk. Early ambulation and adequate pain control prevent the development of delirium in the postoperative setting. (Option 3) Although coexisting medical conditions, such as diabetes mellitus and impaired mobility, predispose to delirium, this client is not at greatest risk. Educational objective: Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control. Test Id: 52138676 Question Id: 33836 (729561) The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? Unordered Options Ordered Response 1. Autonomy 2. Nonmaleficence 3. Paternalism 4. Veracity Explanation The nurse violated the ethical principle "nonmaleficence" (ie, do no harm). It is rare to see a nurse inflict intentional harm. However, problems do occur due to unintentional harm, which is usually a result of poor clinical judgment. Beneficence is a nurse's duty to promote good and do what is best for the client. (Option 1) Autonomy is allowing the clients to choose the direction of their care. This is accomplished with advanced directives along with informed consent and choices regarding proposed treatments. (Option 3) Paternalism is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy. (Option 4) Veracity refers to the duty to tell the truth. This principle should always be applied to client care and documentation. Educational objective: Nonmaleficence is the ethical principle of doing no harm. All nurses must exercise sound clinical judgment to prevent harm, even if it is unintentional, to their clients. Test Id: 52098897 Question Id: 32005 (729561) The nurse reviews the social history of an adolescent client and understands that which behaviors support a diagnosis of conduct disorder? Select all that apply. Unordered Options Ordered Response 1. Blames voices when confronted about misbehavior 2. Fluctuates moods between depression and elation 3. Frequently ignores the curfew established by parents 4. Inserted thumbtacks into the feet of a neighbor's dog 5. Vandalized a painting in a local art museum You answered this question incorrectly. Correct answer is: 4,5 Explanation Conduct disorder is diagnosed when children and adolescents consistently demonstrate behaviors that violate the rights of others. The behaviors are more extreme than those socially acceptable for the child's or adolescent's age. Cruelty to animals and destruction of the property of others are diagnostic of conduct disorder (Options 4 and 5). (Option 1) Clients with schizophrenia, manic or depressive illness, or who are under the influence of a hallucinogenic substance experience auditory hallucinations. Blaming misbehavior on auditory hallucinations does not support the diagnosis of conduct disorder. (Option 2) Adolescents diagnosed with bipolar disorder experience recurrent episodes of mania (elevated mood) and depression. Fluctuating mood does not support the diagnosis of conduct disorder. (Option 3) Children and adolescents with oppositional defiant disorder manifest as defiant and display angry, argumentative, and moody behaviors; however, they do not violate the basic rights of others. Defiant behavior (eg, ignoring parents' rules) does not support the diagnosis of conduct disorder. Educational objective: Conduct disorder involves behaviors that violate social norms and the rights of others. Cruelty to animals and destruction of the property of others are diagnostic behaviors associated with conduct disorder. Test Id: 52098897 Question Id: 33390 (729561) The mental health nurse engaged in dialogue with a client would recognize transference when the client makes which statement? Unordered Options Ordered Response 1. "I can pretend to have feelings; how would you know the difference?" 2. "My roommate doesn't seem to like me very much." 3. "Sharing my thoughts with you will be difficult; you remind me of my sister." 4. "The people who work here do not seem genuine." Explanation The nurse-client relationship is the basis of quality nursing treatment approaches in mental health. It should have clear boundaries that allow for the client to examine feelings and treatment issues. The nurse's needs are clearly separated from the client's needs. However, roles can become blurred when transference and countertransference are not recognized. The act of a client unconsciously displacing (transferring) feelings and behaviors related to a person in the client's past onto the nurse is known as transference. The nurse unknowingly displacing feelings and behaviors about someone in the nurse's past onto the client is known as countertransference. These phenomena disrupt the therapeutic nurse-client relationship. (Options 1, 2, and 4) These client statements do not represent transference. Educational objective: It is important for the nurse to recognize transference in order to maintain a therapeutic nurse-client relationship. Copyright © UWorld. All rights reserved. Test Id: 52098897 Question Id: 30730 (729561) The 17-year-old child of a client being treated for alcoholism tells the nurse that the parent's disease and behavior have taken a toll on the whole family; the child is especially concerned about a 13-year-old sibling who is having trouble in school. The nurse should provide the child with information about what resource? Unordered Options Ordered Response 1. Adult Children of Alcoholics (ACOA) 2. Alateen 3. Alcoholics Anonymous (AA) 4. National Association for Children of Alcoholics (NACOA) Explanation Alcoholism can have profound, negative effects on family members. The term "co- dependent" is used to define family members who have experienced physical or emotional abuse or other pathological conditions as the result of living with someone who is a substance abuser. Co-dependent family members may have a sense of powerlessness, loss of self-esteem, and neglects their own needs to meet the demands of others. Co-dependent persons may engage in their own dysfunctional behavior. There are many resources and self-help groups that provide support to alcohol-addicted individuals and their co-dependents. These include the following: 1. AA - the major self-help organization that provides help and support to individuals who want to stop drinking. AA uses a 12-step approach that provides guidelines on attaining and maintaining sobriety. 2. ACOA - a 12-step, 12-tradition program that provides assistance to adults who grew up in homes that were dysfunctional due to alcoholism 3. Al-Anon - provides help for spouses and significant others of alcoholics to share their own personal experiences and coping strategies 4. Alateen - part of the Al-Anon Family Groups; it provides support to teenagers whose lives have been affected by someone else's drinking 5. NACOA - raises public awareness of the effect of alcoholism on children and family members through leadership in public policy, advocating for prevention services, and providing on-line educational resources 6. Families Anonymous - helps friends and families whose lives have been affected by substance abuse of any kind (Option 1) This organization is for adults. (Option 3) AA provides help to the individual with alcoholism. (Option 4) NACOA provides educational resources but no in-person support services. Educational objective: Alcoholism affects the whole family. Alcoholics Anonymous provides help to the individual who has alcoholism. Alateen provides support to teenagers whose lives have been affected by someone else's drinking. Al-Anon provides help for spouses and significant others of alcoholics. Test Id: 52098897 Question Id: 30524 (729561) A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse? Unordered Options Ordered Response 1. "How long has the oil been leaking from your head?" 2. "Let's go back to your room and look for your headband together." 3. "There is no oil coming out of your head." 4. "You are going to miss breakfast if you do not go into the dining room." Explanation The client, while delusional, is exhibiting signs of anxiety. The priority action for the nurse is to intervene in a manner that will assist in reducing the client's unease. The headband is part of the client's delusional system; it is highly likely that the client will continue to be apprehensive until the headband or substitute is found. Offering to help the client look for the headband conveys a sense of caring and helps establish a trusting relationship. Once the client has calmed down, the nurse will minimize any conversation about the "crack" and the "oil" and can direct the client to reality-oriented activities. Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion. Categories of delusions include the following: • Persecutory – client thinks others are "out to get me" • Ideas of reference – common events refer specifically to the client • Grandiose – client has the perception of special importance or powers that are not realistic • Somatic – false ideas about bodily functioning Nursing interventions include the following: • Not arguing or challenging the belief • Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system. (Option 1) This response focuses on the delusional content and is not therapeutic. It does not help alleviate the client's anxiety. (Option 3) Challenging the delusional content is not therapeutic and will not change the client's belief. (Option 4) This statement does not help reduce the client's anxiety. Educational objective: The priority nursing action for a client exhibiting anxiety is to intervene in a manner that helps make the client feel more at ease. Delusions are fixed, false beliefs; challenging a client's delusional content system will increase the client's anxiety and will not change the client's beliefs. Test Id: 52098897 Question Id: 30828 (729561) A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking and has shortness of breath and heart palpitations. What is the priority nursing action? Unordered Options Ordered Response 1. Encourage the client to perform deep breathing exercises 2. Explore possible reasons for the episode 3. Place the client in a private room and tell the client to relax 4. Stay with the client Explanation This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to offer support and reassurance that the client is safe and secure. Additional nursing actions while the client is experiencing panic symptoms include: • Maintaining a calm, matter-of-fact approach • Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures • Placing the client in a room with as little stimuli as possible • Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription) • Having the client breathe into a paper bag if hyperventilation is a problem (Option 1) Breathing into a paper bag, not deep breathing exercises, is the best strategy for relieving hyperventilation. (Option 2) Discussing the reasons for the panic attack is not appropriate while the client is still symptomatic. Once the client has calmed down, the nurse can discuss reasons for the attacks, evaluate stressors in the client's life, and assist the client in developing prevention strategies. (Option 3) A private room is appropriate; however, just telling a client to relax is not helpful. Educational objective: The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment and offer support and reassurance that the client is safe and secure. Test Id: 52098897 Question Id: 32806 (729561) A client with moderate Alzheimer disease is started on memantine. In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following? Unordered Options Ordered Response 1. Improved ability to perform activities of daily living 2. Indications that disease progression has stopped 3. Rapid improvement in cognitive functioning 4. Reversal of the disease Explanation Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the quality of life for clients and caregivers. Memantine is an N- methyl-D-aspartate (NMDA) antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from overexposure to glutamate (excess levels of glutamate contribute to brain cell death). Clients with moderate to severe AD may experience improvement in: • Cognition – memory, thinking, language • Daily functioning – dressing, bathing, grooming, eating • Behavioral problems – agitation, depression, hallucinations (Option 2) Memantine delays but does not stop progression of some symptoms of moderate to severe AD. (Option 3) Memantine does not cause rapid improvement of cognitive functioning; it usually takes weeks or months before such improvement is noticeable. (Option 4) Memantine does not reverse the degenerative process of AD. Educational objective: Memantine is a medication used in the treatment of moderate to severe Alzheimer disease (AD). It slows the progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive functioning, and ability to perform activities of daily living. Test Id: 52098897 Question Id: 30729 (729561) A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for most of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the best nursing action? Unordered Options Ordered Response 1. Engage other staff members to remove the client from the bathroom 2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break 3. Tell the client that the bathroom is very clean and that this behavior is unreasonable 4. Tell the roommate to use the shower in another room Explanation Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions (recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will experience increased anxiety. A client with compulsive behavior often does not realize the amount of time or how many times the same activity has been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-solving skills. (Option 1) Engaging other staff members to remove the client from the bathroom is confrontational and will increase the client's and roommate's anxiety; this approach is not necessary or therapeutic. (Option 3) Pointing out that the bathroom is clean does not change the client's obsessive thoughts. Saying that the client's behavior is unreasonable conveys a message of disapproval and would increase the client's anxiety. (Option 4) Telling the roommate to use a different bathroom allows the client to continue the ritualistic behavior, is non-therapeutic, reinforces the behavior, and avoids the issue. Educational objective: Clients with OCD engage in rituals and activities that help reduce the anxiety associated with unacceptable thoughts, images, and impulses. Therapeutic approaches to a client with OCD include pointing out the amount of time the client has spent performing an activity and redirecting the client to another activity. Test Id: 52098897 Question Id: 32805 (729561) The daughter of an 80-year-old client recently diagnosed with Alzheimer disease says to the nurse, "I can anticipate getting this disease myself at some point." What is the best response by the nurse? Unordered Options Ordered Response 1. "Have you suffered any recent head trauma?" 2. "If you modify your lifestyle, you can reduce your risk of familial Alzheimer disease." 3. "It is good that you recognize this now so you can plan for your future care." 4. "Not necessarily. The strongest known risk factor for Alzheimer disease is age." Explanation Alzheimer disease (AD) is most likely caused by a combination of genetic, environmental, and lifestyle factors. However, according to the National Institutes of Health, the strongest known risk factor for late-onset AD is advancing age. Most clients with AD receive the diagnosis after age 60. The chance of developing AD doubles about every 5 years after age 65; at age 85, the risk for developing AD is 50%. In a very rare form of AD known as familial AD (autosomal dominant AD), multiple generations are affected. Signs and symptoms may appear during early to middle adulthood, and the diagnosis is made before age 60. (Option 1) Research indicates that serious head injury increases the risk of developing AD in the future; however, advancing age is the strongest and most important risk factor. (Option 2) Although some research suggests an association between modifiable lifestyle factors (ie, diet, exercise, smoking) and a reduced risk for late-onset AD, early- onset familial AD is caused by a gene mutation. (Option 3) There is no indication that the client has true familial AD. The most significant risk factor for the client's daughter is advancing age. Educational objective: The development of Alzheimer disease (AD) is influenced by a combination of genetic, lifestyle, and environmental factors. The most significant and strongest risk factor for late-onset AD is advancing age. Test Id: 52098897 Question Id: 30926 (729561) Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. Unordered Options Ordered Response 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight Explanation Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: 1. Fear of weight gain – clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. 2. Fluid and electrolyte imbalance – excessive vomiting can cause hypokalemia and metabolic alkalosis 3. Amenorrhea – clients are often amenorrheic due to decreased body fat (low estrogen) 4. Decreased metabolic rate – severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance 5. Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. (Option 3) Anorexia nervosa manifests as cold intolerance. (Option 5) Anorexia nervosa manifests as lengthy and vigorous exercise. Educational objective: The clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea, bradycardia, cold intolerance, dry skin, and lanugo. Life-threatening complications, such as cardiac arrhythmias associated with hypokalemia, may develop Test Id: 52098897 Question Id: 30535 (729561) A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.… I can get out of anything. There could be trouble now." Which of the following is the best response to this client? Unordered Options Ordered Response 1. "How are you feeling now?" 2. "How did you manage to get out of the restraints?" 3. Say nothing but signal to other staff that assistance is needed 4. "What kind of trouble are you thinking about?" Explanation In this situation, the priority nursing action is to quickly and calmly assess this client's present risk for violence before implementing an intervention. This client's statement, "There could be trouble now," has multiple possible meanings (eg, Is the nurse "in trouble" as the restraints may not have been applied properly? Are the other clients in the unit "in trouble" as this client is out of restraints? Is this client "in trouble" due to thoughts of self-harm?). Seeking clarification of this client's statement is a therapeutic communication technique that will help the nurse determine the next steps in providing care. Mechanical restraints may be necessary only as a last resort for a client at high risk for violence, self-directed or other-directed. Clients placed in restraints must be observed and monitored frequently for: • Assisting with hydration, elimination, and positioning • Ensuring that circulation is not compromised • Determining readiness for removal of restraints (Option 1) It is important to ask this client about current feelings. However, in this situation, the priority is to clarify this client's statement. (Option 2) This statement is immaterial; it is important to assess this client's current status. (Option 3) Assistance from another staff member may be necessary if this client is still at high risk for violence; this client needs to be assessed first. Educational objective: A client at high risk for violence, self-directed or other-directed, may need to be placed in restraints as a last resort. Frequent monitoring and assessment through observation and use of therapeutic communication techniques will help determine if a client is ready to have restraints removed. Test Id: 52098897 Question Id: 31961 (729561) A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? Unordered Options Ordered Response 1. The nurse has encouraged exploration of the client's situation 2. The nurse has shown interest in the client's concerns 3. The response conveys empathy toward the client and promotes self-confidence 4. The response devalues the client's feelings and gives false reassurance Explanation The nurse has used a nontherapeutic communication technique known as "giving reassurance" or "giving false reassurance." A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. This technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued. (Option 1) The nurse has not encouraged exploration of this client's feelings and options. This could have been done by using any one of several therapeutic communication techniques (eg, reflecting, focusing, exploring). An appropriate response by the nurse, such as stating, "Tell me what concerns you have," would have facilitated communication with the client. (Option 2) The nurse has shown no interest in the client's concerns; instead, the nurse should show interest, be available, and have a conversation with the client (eg, "I will stay and listen to your concerns"). (Option 3) The nurse has not conveyed empathy (attempting to understand and share the feelings behind a client's actions and words). An empathetic nurse might say, "This must be hard for you," or, "I understand you are upset." Educational objective: The nurse must learn to use effective therapeutic communication skills to enhance the development of a trusting and therapeutic nurse-client relationship. Test Id: 52098897 Question Id: 31082 (729561) The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take? Unordered Options Ordered Response 1. Ask the client to make a verbal contract to not harm self 2. Document that the client is not currently suicidal 3. Place the client in an inside hallway with one-on-one observation 4. Return the client to the waiting room with the spouse Explanation Any client who cannot definitively say that currently he/she is not suicidal should be considered a "yes" and appropriate protective measures should be instituted to prevent suicidal actions. The client is under the hospital's care and the department must assume responsibility for the client's safety. Placing the client in an inside hallway can prevent the client from running outside. The client needs constant supervision by a hospital employee until a secure room is available. The client should never be left alone without hospital supervision. (Option 1) A verbal contract is a viable option but might not be accomplished appropriately in the triage area. Also, its efficacy is questionable. Emergency department triage should be accomplished in 3-5 minutes. In addition, the triage nurse may not have the skills to adequately perform this intervention. Safety should always be the first priority, and precautions should be taken until the client is determined to not be suicidal. (Option 2) Any ambivalence, especially given the client's previous actions and statements, should be considered a "yes." (Option 4) It is unfair to expect the spouse to perform the same level of care as a health care provider; the spouse brought the client to the hospital for additional help. It would be appropriate to have the spouse present with the client in a secure setting. The spouse would also be instructed to keep the client in sight at all times. Having the client and spouse return to the waiting room would provide the opportunity for the client to bolt from the hospital. Educational objective: Any client who expresses ambivalence about being suicidal should be treated as a "yes." The client must be in a safe environment with hospital supervision and should not be left alone. Test Id: 52098897 Question Id: 30629 (729561) A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse? Unordered Options Ordered Response 1. "I will help you get ready; then we can walk to the dining room together." 2. "I'll have breakfast brought to your room." 3. "It's okay. You can join us when you are ready." 4. "You'll feel better when you get up." Explanation Reduced appetite and low energy level are common clinical findings in major depressive disorder. The lethargy accompanying the depressed mood makes it difficult for a client with this diagnosis to even get up and out of bed. Personal hygiene and grooming are neglected, and there is no desire to interact with others. The client needs direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self esteem. (Option 2) This action reinforces the client's desire to stay in the room and is not therapeutic. (Option 3) This response is non-therapeutic; the client needs assistance with ADLs. (Option 4) Clients with depression often do feel better after even minimal exercise and activity. However, this response does not give the client direction or structure. Educational objective: Clients with low energy, lethargy, or fatigue associated with major depressive disorder need structure and direction in performing basic ADLs, including personal hygiene and grooming. The nurse needs to provide assistance to the client in completing ADLs and in initiating social interaction with others. Test Id: 52098897 Question Id: 30631 (729561) A client with severe major depressive disorder is lying in bed and has not moved for 3 hours. The client will respond slowly to "yes" and "no" questions; otherwise, the client does not respond when spoken to. The clinical manifestations exhibited by the client are known as: Unordered Options Ordered Response 1. Psychogenic dystonia 2. Psychogenic gait 3. Psychomotor retardation 4. Somatization Explanation Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. The individual may not have the energy or ability to perform activities of daily living or to interact with others. Psychomotor retardation may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior). Specific clinical findings of psychomotor retardation include the following: • Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait • Lack of facial expression • Downcast gaze • Speech impairment – reduced voice volume, slurring of speech, delayed verbal responses, short responses • Social interaction – reduced or non-interaction Clients with major depressive disorder may also show symptoms of psychomotor agitation, characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye movement. (Option 1) Psychogenic dystonia is a psychogenic movement disorder characterized by involuntary muscle contractions that cause slow, repetitive movements such as twisting and abnormal postures. (Option 2) Psychogenic gait is a psychogenic movement disorder characterized by unusual standing postures and walking. The client may experience knee buckling and falling or may veer from side to side as if staggering. (Option 4) Somatization is a term to describe physical symptoms that cannot be explained by a medical condition or disease. Educational objective: Psychomotor retardation is a clinical finding in some clients diagnosed with major depressive disorder. The key features include decreased movement, inability or decreased ability to talk, and impaired cognitive function. Test Id: 52098897 Question Id: 30552 (729561) A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take? Unordered Options Ordered Response 1. Ask where the client is going 2. Immediately follow the client out the door 3. In a loud voice, direct the client to come back to the room 4. Remain silent and allow the client to leave Explanation Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a poor quality of life. Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the following: • Making brief, frequent contacts • Accepting the client unconditionally by minimizing expectations and demands • Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients • Being with or close by the client during group activities • Offering positive reinforcement when the client interacts with others (Option 1) Asking where this client is going is nontherapeutic as it requires an explanation of the client's actions. (Option 2) Following this client out the door could increase the client's anxiety. (Option 3) Directing this client to come back to the room is placing a demand that may be unrealistic and does not help develop a sense of trust. Educational objective: Social isolation and impaired social interaction are common negative symptoms of schizophrenia. The client will seek to be alone to relieve anxiety associated with being around others. The nurse needs to be accepting of the client's behavior and continue attempts at brief contact until the client is comfortable. Test Id: 52098897 Question Id: 30820 (729561) A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse; I know you'll be a good sport and give me a pass." What is the best response by the nurse? Unordered Options Ordered Response 1. "I guess the day shift staff needs to be reminded of the rules." 2. "The gift shop is not even open right now." 3. "Why do you want to go to the gift shop?" 4. "You do not have privileges for leaving the unit. I cannot give you a pass." Explanation Manipulative behaviors such as attempts at staff splitting are common in adult clients who have other immature personality traits. Typically these behaviors are associated with personality disorders (eg, borderline personality disorder, anti-social personality disorder), substance abuse, somatic symptom disorder, and the manic phase of bipolar disorder. The manipulative behavior is aimed at gaining control or power over a person or situation or for material gratification. Clients manipulate with flattery and by pitting staff members against each other. They may "tell" on a staff member or act in a way to give the impression of sincerity and caring. Nursing strategies for addressing manipulative behaviors include: • Setting limits that are realistic, not punitive, and enforceable • Using a non-threatening, matter-of-fact tone when discussing set limits and the consequences of unacceptable behaviors • Enforcing all unit, hospital, or center rules • Consistency from all staff members in enforcing limits set for the client in the nursing care plan (Option 1) This is not an appropriate response and will only reinforce the client's manipulative behavior. (Option 2) This does not address the client's manipulative behavior. (Option 3) This is not an appropriate response; it ignores the fact that the client is trying to break the rules. Educational objective: Clients who need to gain power or control over a situation or desire material gratification may use manipulative behaviors such as staff splitting to get what they want. Appropriate nursing interventions include setting behavioral limits; using a neutral, matter-of-fact tone when discussing rules and the consequences of unacceptable behavior; and consistency from staff members in following the client's nursing care plan. Test Id: 52098897 Question Id: 33595 (729561) A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? Unordered Options Ordered Response 1. "How dare they change my appointment? I insist that the procedure be done at 10:00 AM." 2. "That's fine. I can come in whenever it is convenient for everyone." 3. "This is unacceptable. I had my whole day planned out." 4. "Why are they doing this to me?" Explanation Individuals with obsessive-compulsive personality disorder are typically self-willed and obstinate, punctual, pay attention to rules and regulations, and need to control both internal and external experiences. These traits are very extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for the day and is outside of the client's control. This could cause significant distress and impaired functioning so that the client feels emotionally paralyzed. (Option 1) This response is characteristic of a client with narcissistic personality disorder, who may behave in grandiose, demanding, and entitled ways and needs to have his/her own way. (Option 2) This response could be attributed to a client with dependent personality disorder, who tends to be passive and submissive and wants to please others. (Option 4) This response would be more characteristic of an individual with paranoid personality disorder, who may feel slighted or is overly sensitive. Educational objective: An individual with obsessive-compulsive personality disorder is typically rigid and inflexible and has a need to control both internal and external experiences. A change in a schedule that is outside of the client's control could cause significant distress. Test Id: 52098897 Question Id: 32003 (729561) The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse prioritize? Unordered Options Ordered Response 1. Acknowledges poor interpersonal skills 2. Identifies new coping mechanisms 3. Increases caloric intake to gain weight 4. Verbalizes sources of conflict and anger You answered this question correctly. Explanation Anorexia nervosa is an eating disorder characterized by distorted body image, profound fear of weight gain, a strong desire to be thin, and being unwilling to maintain a healthy body weight. The client engages in behaviors to lose weight, including not eating, purging, extreme exercise, and use of laxatives and diet pills. Psychosocial issues leading to anorexia are the focus of ongoing therapy, usually on an outpatient basis. However, certain criteria require hospitalization and include body weight below 75% of ideal, suicidal behavior, or medical conditions resulting from starvation. The priority focuses during inpatient care are the short-term outcomes of restoring caloric intake, promoting gradual weight gain, and treating medical conditions caused by starvation. (Options 1, 2, and 4) Acknowledging poor interpersonal skills, identifying new coping mechanisms, and verbalizing sources of conflict and anger are important but will not be the focus during hospitalization. These long-term outcomes will be addressed during ongoing therapy. Educational objective: Treatment for a client requiring hospitalization for anorexia nervosa should focus on the short-term outcomes of increasing caloric intake, promoting gradual weight gain, and addressing medical conditions caused by starvation. Test Id: 52098897 Question Id: 30920 (729561) After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the best response by the nurse? Unordered Options Ordered Response 1. "But you look so thin." 2. "I don't see you that way; you are making progress toward a healthy weight." 3. "If you continue to gain weight at this rate, you will be able to go home soon." 4. "You are not fat; it's all in your imagination." Explanation A nursing diagnosis associated with anorexia nervosa is disturbed body image/low self esteem. There is often a large disparity between actual weight and the client's perceived weight. Clients with anorexia nervosa think of themselves as overweight and fat. The nursing care plan should include helping the client develop a realistic perception of weight and body image. The nurse can confront the client about the misinterpretation of body weight by presenting reality without challenging the client's illogical thinking. The client's weight should be discussed in the context of overall health. The nurse also needs to be aware of his/her own reaction to the client's behaviors and statement. It is not uncommon for caregivers and care providers to feel frustrated or even angry when caring for a client with an eating disorder. The nurse must maintain a neutral attitude and approach, avoiding arguing or disagreeing with the client's statements. (Option 1) This response is judgmental, reinforces the idea of "thinness," and does not help the client develop a more realistic body image. (Option 3) Establishing a goal weight is part of the nursing care plan for the client with anorexia nervosa; clients are usually not discharged from inpatient treatment until goal weight is achieved. However, this response does not address the client's misperception of body weight. (Option 4) This response dismisses the client's concern and does not present the reality of the situation. Educational objective: Clients with anorexia nervosa have disturbed body image and see themselves as being fat or overweight even when they are severely underweight or even at a normal body weight. The nurse can help the client develop a more realistic self image by presenting the situation realistically and discussing weight in terms of the client's health. Test Id: 52095998 Question Id: 30794 (729561) The parent of an adolescent calls the mental health crisis hotline and says, "I just watched a TV program about bulimia and I think my child may have this disease." What is the most likely reason that the parent came to this conclusion? Unordered Options Ordered Response 1. The adolescent has been wearing bulky, oversized clothing. 2. The adolescent has lost 20 lb (9 kg) in 2 months. 3. The adolescent stopped going to the gym. 4. The parent has found numerous candy, cake, and cookie wrappers under the adolescent's bed. Explanation Bulimia nervosa is characterized by episodes of uncontrollable binge eating (consuming very large amounts of food) followed by inappropriate behaviors to prevent weight gain. Self-induced vomiting within 1-2 hours of binge eating is the more typical behavior; use of enemas and laxatives, and frequent, intense exercise are also characteristic behaviors of the client with bulimia nervosa. Signs that a parent or friend of someone with this disorder might notice include the following: • Trips to the bathroom after meals • Disappearance of large amounts of food • Finding hidden wrappers and empty containers of food, especially foods that are sweet and easily consumed • Smells of vomit; finding packages of laxatives or enemas • Getting up in the middle of the night followed by a trip to the bathroom some time later • Engaging in intense physical exercise despite fatigue or pain • Swelling of the cheeks due to parotid gland damage and enlargement; staining of the teeth • Periods of starvation • Preoccupation with weight, food, and dieting (Option 1) This behavior is more characteristic of clients with anorexia nervosa, who may wear oversized, bulky clothing to hide weight loss. (Option 2) Severe weight loss is characteristic of anorexia nervosa; clients with bulimia nervosa usually maintain a normal or just-above-normal weight. (Option 3) A client with bulimia nervosa would more likely increase the amount of time spent exercising. Educational objective: Characteristic behaviors of a client with bulimia nervosa include binge eating followed by self-induced vomiting, use of laxatives, and/or intense exercise. Test Id: 52095998 Question Id: 30287 (729561) Which client statement demonstrates mental health well-being when considering stress and anxiety? Unordered Options Ordered Response 1. "I know that relaxation techniques help me deal with my life's stress and anxiety." 2. "I understand stress and anxiety because my family has a history of depression." 3. "You must understand that stress and anxiety affect everyone's life." 4. "You should identify and then avoid those things that cause you stress and anxiety." Explanation Well-being is demonstrated by the ability to cope with routine stress and continue to function adequately even with the resulting anxiety. (Option 2) Understanding the concepts of stress and anxiety does not ensure ability to cope effectively to maintain mental health well-being. (Option 3) Understanding that stress and anxiety are present in daily life does not ensure the ability to cope effectively to maintain mental health well-being. (Option 4) Although it may be possible to identify one's stress and anxiety triggers, it is not possible to avoid them all. Coping techniques are required to maintain mental health well-being. Educational objective: The mental health continuum uses a continuous line to represent the transition from mental health to mental illness. This passage varies from person to person and within an individual over time but is demonstrated by the ability to cope and function effectively with routine stress and anxiety. Test Id: 52095998 Question Id: 32415 (729561) A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? Unordered Options Ordered Response 1. Allow the child to stay home when the child seems particularly anxious 2. Encourage the parent/caregiver to sit in the classroom with the child 3. Insist on school attendance immediately, starting with a few hours a day 4. Return the child to school when the cause of the school phobia has been identified Explanation School phobia (also known as school refusal or school avoidance) is a childhood anxiety disorder in which the child experiences an irrational and persistent fear of going to school. Having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery. If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day. A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships. (Option 1) Allowing the child to stay home will only reinforce the acting-out behaviors associated with refusal to attend school. The parent/caregiver needs to support the child and talk about the cause of the anxiety, but the child needs to go to school. (Option 2) Having the parent/caregiver stay in the classroom with the child is not a permanent solution to relieving the child's anxiety and is not recommended. (Option 4) Determining the cause of the school phobia is important in helping to alleviate the child's symptoms and in coping with the return to school. However, returning the child to the classroom immediately is the most important action. Educational objective: A child with school phobia needs to return to the classroom immediately. Insisting on school attendance, along with other supportive interventions, will help the child make a faster adjustment. Test Id: 52095998 Question Id: 32117 (729561) A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD). She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar." What is the best response by the nurse? Unordered Options Ordered Response 1. "It may take time to overcome those thoughts and feelings." 2. "Those kinds of thoughts are self-destructive. You should stop thinking about it." 3. "You could not have anticipated the rape. You did not deserve or ask for it." 4. "You have to stop blaming yourself so you can move on with your life." Explanation One of the common features of PTSD is a persistent distorted perception about the cause of the traumatic event that leads the affected individuals to blame themselves or others. Clients may be in a persistent, negative emotional state of guilt and/or shame and also believe that they are responsible for what happened. This is particularly true in cases of rape. A pervasive culture of "blaming the rape victim" also contributes to clients' perception that the rape was somehow their own fault. Providing a realistic perspective of the rape may help clients develop a more objective view of their perceived role in the traumatic event and may reduce feelings of self-blame and guilt. The nurse needs to reinforce repeatedly that rape is never the victim's fault (Option 3). (Option 1) This is a nontherapeutic response as it reinforces the client's feelings of self-blame and guilt. The best therapeutic response should reinforce that the client is not to blame for the rape. (Option 2) This is a nontherapeutic response; it does not assist in changing the client's perception of the traumatic event and implies that the client should not cope with the experience at all. (Option 4) This is a nontherapeutic response. Clients cannot simply make negative feelings disappear; these need to be resolved through therapy. Educational objective: Clients who suffer from PTSD often experience feelings of guilt and shame; they believe that they are responsible for what happened and that, somehow, they could have prevented the traumatic event. Using therapeutic communication, the nurse needs to convey that what happened was not their fault. Test Id: 52095998 Question Id: 31748 (729561) The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is most consistent with the diagnosis of delirium? Unordered Options Ordered Response 1. Client is alert but disoriented to time 2. Client is inattentive and hallucinating 3. Client reports decreased enjoyment in previously pleasurable activities 4. Family reports a gradual progressive inability to remember recent events Explanation The Confusion Assessment Method (CAM) is used to determine delirium. The signs are acute mental status changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and pain. Delirium has an abrupt onset and is a symptom of other problems. Up to 60% of hospitalized elderly clients have delirium prior to or during hospitalization, but it is often missed by nursing. (Option 1) This can be due to dementia or just an acute mental status change. Further assessment would be necessary. However, fluctuating mental status changes and inattention that are characteristic of delirium are not present in this client. (Option 3) This is a sign of depression. Two simple screening questions for depression include the following: "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" "During the past month, have you often felt minimal interest or pleasure in doing things you used to enjoy?" (Option 4) This describes dementia. Its onset is slow and insidious, and family members usually notice it first. The client's attention level is usually normal. Educational objective: Delirium has a sudden onset and involves fluctuating mental status and inattention with disorganized thinking and/or altered level of consciousness. Dementia has a slow onset, usually with normal attention. Depression involves loss of interest in previously pleasurable activities. Test Id: 52095998 Question Id: 32610 (729561) After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction? Unordered Options Ordered Response 1. Ensure that the client is never left alone 2. Notify neighbors of the client's tendency to wander 3. Place a chain lock on the door above or below the client’s eye level 4. Place a safe return bracelet on the client’s non-dominant hand Explanation Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy to prevent wandering is to make modifications to secure the environment. These include: • Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads (Option 3). • Adding a motion sensor or alarm that goes off when someone tries to exit • Placing a large stop sign on door exits • Disguising a door with a curtain or wall hanging • Using childproof doorknob covers • Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception. (Option 1) Clients with AD should not be left alone; however, it is impossible for any caregiver to watch another person every minute of the day. Clients with AD can walk out of their homes while family members are sleeping. (Option 2) Notifying neighbors can be helpful if the client leaves the residence but will not prevent wandering. (Option 4) Safe return or identification bracelets are important, but they will not prevent wandering. A bracelet should be placed on the dominant hand to minimize the chance of removal. Educational objective: The most effective strategy to prevent clients with dementia from wandering is to make modifications to secure their environment. These include installing locks above or below eye level on doors, hiding exits with wall hangings or curtains, placing a black mat in front of exits, and using doorknob covers, motion detectors, and alarms. Test Id: 52095998 Question Id: 32885 (729561) A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake most of the night, feel exhausted, and do not know what to do." What is the best response by the nurse? Unordered Options Ordered Response 1. "Do not let your mother take naps in the afternoon." 2. "Our social worker can discuss long-term care options with you." 3. "We can ask the health care provider for medication that will help your mother sleep." 4. "Your mother can be cared for in a nursing home." Explanation This caregiver is experiencing high levels of stress and exhaustion related to caring for the client; without help, the caregiver could easily experience burnout. A social worker can provide information on resources and services for assistance and support; these include adult day programs, in-home assistance, visiting nurse services, and home-delivered meals. The social worker can also provide the names of agencies that seek the support of others in similar situations (eg, local chapter of the Alzheimer's Association). (Option 1) Keeping a client with Alzheimer disease awake during the day is a behavioral strategy that may reduce the risk of sundowning (increased confusion and agitation in the evenings). However, this response does not address the caregiver's stress and exhaustion. (Option 3) Antipsychotic medications are used cautiously in elderly clients with dementia due to the high risk of a cardiovascular event. This response does not provide an effective approach to the caregiver's increasing levels of stress. (Option 4) Institutional care may be the best option for this client. However, giving an opinion or telling the caregiver what the appropriate action "should" be is a non- therapeutic response. Educational objective: Caregivers of clients with Alzheimer disease and other types of dementia often experience burnout due to stress and exhaustion. They need information on community resources that can provide assistance with client care. Test Id: 52095998 Question Id: 31959 (729561) The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? Unordered Options Ordered Response 1. "I need for you to get rid of these bugs that are crawling under my skin." 2. "Hear that? She told me to kill my father." 3. "That song is a message sent to me in secret code." 4. "Those Martians are trying to poison me with the tap water." Explanation Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs, newspaper articles, and other events are personal and significant to them. Other examples of delusions are below: • Grandeur – "I need to get to Washington for my meeting with the president." • Control – "Don't drink the tap water. That's how the government controls us." • Nihilistic – "It doesn't matter if I take my medicine. I'm already dead." • Somatic – "The doctor said I'm fine, but I really have lung cancer." (Option 1) This client statement is an example of a tactile hallucination, which gives the client the sensation of being touched. (Option 2) This client statement is an example of an auditory hallucination, specifically a command hallucination. Clients experiencing auditory hallucinations hear sounds and voices others do not. (Option 4) This client statement is an example of a persecutory (paranoid) delusion. Clients with such delusions believe that they are being threatened or treated unfairly in some way. Educational objective: Delusions are a positive symptom of schizophrenia. Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them. Test Id: 52095998 Question Id: 30921 (729561) A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy? Unordered Options Ordered Response 1. The client and spouse are soon moving into a new neighborhood 2. The client's boss has asked the client to represent the company at an upcoming convention 3. The client's primary health care provider (HCP) of 30 years is retiring and the client will be seeing a new HCP 4. The client's son is getting married in a few months Explanation Social anxiety disorder (SAD) is characterized by an excessive and persistent fear of social or performance situations in which the client is exposed to strangers and the possibility of scrutiny by others. Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public, and giving a speech. The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and blushing. Although all these situations could provoke some degree of anxiety in a client with SAD, having to represent the company at a convention with hundreds of strangers is most likely what brought this client to the community mental health center. Clients with SAD often have anticipatory anxiety and worry for days or weeks before a feared event. They may recognize that their fear is exaggerated and will seek assistance and counseling. (Option 1) The prospect of a new neighborhood may cause the client some anxiety; however, in this situation, the client has some control over exposure to new neighbors. The client can control this fear by limiting encounters or avoiding the neighbors altogether. (Option 3) Seeing a new HCP may cause some degree of discomfort in a client with SAD; however, as a one-on-one encounter, it is not like to cause severe anxiety or panic. (Option 4) In this situation, the client will be around familiar and possibly unfamiliar people. If necessary, the client can create a comfort zone by limiting contact with unfamiliar people. Educational objective: Clients with social anxiety disorder have an excessive, persistent fear of social or performance situations involving strangers and the possibility of criticism, embarrassment, humiliation, and rejection. The fear of the situation(s) causes severe anxiety and avoidance. Test Id: 52095998 Question Id: 30558 (729561) A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action? Unordered Options Ordered Response 1. Administer 5 mg inhaled albuterol nebulizer treatment to decrease inflammatory bronchoconstriction 2. Administer 100% oxygen using a nonrebreather mask with flow rate of 15 L/min 3. Administer methylprednisolone to decrease lung inflammation from toxic inhalant 4. Titrate oxygen to maintain pulse oximeter saturation of >95% Explanation The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the tissues. It must be able to pick up oxygen and release it in the right places. Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. The nurse's primary action is to administer highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse this displacement of oxygen. (Option 1) Albuterol is not a priority action as bronchoconstriction is not a consequence of CO poisoning. (Option 3) Administration of corticosteroids is not a priority/primary action as direct inflammation of the lungs is not an underlying cause for hypoxemia and hypoxia associated with CO poisoning. (Option 4) When all available Hgb binding sites are occupied (oxyhemoglobin or carboxyhemoglobin), saturation (SaO2) is 100%. The conventional pulse oximeter cannot differentiate carboxyhemoglobin from oxyhemoglobin as both absorb the oximeter's red and infrared light wavelengths. Consequently, the pulse oximeter reading may be adequate (>90%), but severe hypoxemia and hypoxia may be present. Alternate methods of CO saturation measurement (eg, multiple wavelength CO pulse oximeter, spectrographic blood gas analysis) are recommended. Educational objective: The conventional pulse oximeter is not effective in identifying hypoxia in CO poisoning; diagnosis requires co-oximetry of a blood gas sample. The priority action is to administer 100% oxygen using a nonrebreather mask to treat hypoxia and help eliminate CO. Test Id: 52095998 Question Id: 30012 (729561) The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse? Unordered Options Ordered Response 1. "I know it must be terrible to see your son like this, but he will be fine." 2. "Most people have permanent side effects after an episode like this." 3. "Your son will have to remain here for observation until we know more." 4. "Your son would be fine right now if he had not taken these drugs." Explanation It is important to distinguish clinically between the very similar presentations of intoxication, delirium secondary to a medical condition, dementia, and psychiatric disorders involving distorted perceptions of reality in order to begin the appropriate treatment. Some illicit substances (eg, marijuana, LSD, PCP) have been reported to cause episodes of severe, acute psychosis. Some clients will never experience another episode of psychosis. However, in rare cases, illicit substances may trigger a genetic predisposition to development of a mental illness. There is no way to establish the long- term prognosis. (Option 1) The long-term prognosis after an episode of psychosis is impossible to predict with any accuracy. It is tempting to offer comfort to a client's family in a time of crisis, but the nurse should never make promises. (Option 2) Most cases of drug-induced psychosis are transient. (Option 4) After substance abuse has been verified, client education regarding drug abuse and therapy or counseling are indicated. However, it is extremely unprofessional to judge clients for their behavior and lifestyle choices. Educational objective: Clients demonstrating altered mental status should be assessed for intoxication and medical causes of delirium (electrolyte/glucose imbalances, pneumonia, sepsis, malnutrition) prior to involving a mental health care professional Test Id: 52095998 Question Id: 30577 (729561) A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse? Unordered Options Ordered Response 1. Give the client a book to read 2. Provide earphones and a DVD player and have the client sing along with the music 3. Tell the client that the voices will go away when the medication starts to work 4. Tell the client to ignore the voices Explanation Auditory hallucinations are the most common type of hallucination and are typically experienced by individuals with a diagnosis of schizophrenia, bipolar disorder, or other psychotic illness. Antipsychotic medication therapy is the first-line treatment of hallucinations and other psychotic symptoms. However, most psychotropic drugs may take some time to be completely effective and may not eliminate hallucinatory episodes entirely. Clients should be encouraged to develop alternate methods for coping with the hallucinations. One approach is increasing the amount of external auditory stimulation in the environment. Individuals with auditory hallucinations have reported that increasing the amount of external sound (eg, watching TV or listening to music through headphones) makes it easier to ignore internal sounds from the hallucinations. Other methods of managing auditory hallucinations include voice dismissal (telling the voices to go away) and cognitive behavioral therapy (assists clients in learning new ways to think about and deal with their symptoms). (Option 1) Reading a book may provide some distraction, but it does not increase external auditory stimulation. (Option 3) The medication may not start to work for another 2 weeks and may not eliminate these symptoms entirely. (Option 4) The client is hearing voices all day long; ignoring them is not as effective as an activity that distracts the client from the hallucinations. Educational objective: Although antipsychotic medication is the first-line treatment for diminishing or eliminating psychotic symptoms, such as hallucinations, clients need other strategies for coping with distressing symptoms. Increasing external auditory stimulation often helps distract the client from the internal voices and focus on reality. Test Id: 52095998 Question Id: 30984 (729561) The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply. Unordered Options Ordered Response 1. Allow client to remain on current laxatives 2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 1-2 hours after each meal in a central area Explanation Bulimia nervosa is an eating disorder common among adolescent girls and characterized by cycles of uncontrollable overeating (binging) followed by compensating behaviors to avoid weight gain (purging). Weight-maintenance behaviors include self- induced vomiting, fasting, laxative abuse, and excessive exercise. Clients may be of normal weight, which contributes to the hidden nature of this disorder. Clients with bulimia often experience extreme guilt associated with their increasing lack of control and attempt to hide evidence of their actions (eg, hidden food wrappers from binging, discarded food from unfinished meals). Clients should be monitored around meal times, and particularly for 1-2 hours after eating to observe for purging. Purging behaviors, particularly vomiting, may result in electrolyte imbalances, such as hypokalemia, that can cause cardiac arrhythmias. (Option 1) Clients with bulimia nervosa often use laxatives inappropriately to rid their bodies of undigested food in an effort to control their weight. Such measures should not continue in the treatment setting. (Option 4) A food diary helps the client and caregivers track the type and amount of food that the client has eaten. It is also an excellent means of helping the client understand the health implications of the disorder. Educational objective: Clients with bulimia nervosa should be monitored for signs of hidden binging or purging activity, particularly for 1-2 hours after meals. Excessive vomiting may result in electrolyte imbalances, including hypokalemia. Test Id: 52095998 Question Id: 33458 (729561) The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room." Which statement best explains the client's behavior? Unordered Options Ordered Response 1. The client has a problem with authority figures 2. The client has an intense need to control the environment 3. The client is hearing voices 4. The client is trying to control anger Explanation Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that people's motives are malicious and assume that others are out to exploit, harm, or deceive them. These thoughts permeate every aspect of their lives and interfere with their relationships. Individuals with paranoid personality disorder are usually difficult to get along with as they may express their suspicion and hostility by arguing, complaining, making sarcastic comments, or being stubborn. Because these clients do not trust others, they have a strong need to be self-sufficient and maintain a high degree of control over their environment. (Option 1) This statement best describes an individual with antisocial personality disorder. (Option 3) Clients with paranoid personality disorder do not have psychotic symptoms. (Option 4) Clients with paranoid personality disorder will usually not be able to control their anger when confronted with a real or imagined threat. Educational objective: Paranoid personality disorder is characterized by distrust and suspicion of others. Because these clients do not trust other people, they have an intense need to control them and their environment. Test Id: 52095998 Question Id: 33435 (729561) The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is most therapeutic at this time? Unordered Options Ordered Response 1. "It would be helpful if you could look at me while we talk." 2. "We can finish our conversation later; thank you for speaking with me." 3. "What do you see at the door?" 4. "When you don't look at me, I feel like you don't trust me." Explanation The goal of therapeutic communication with clients diagnosed with schizophrenia is building trust, self-awareness, reality testing, and self-confidence. The nurse should be aware of client cues that indicate hallucinations (distraction, mumbling, watching a vacant area of the room). This client might be having a visual hallucination, as evidenced by being distracted and grimacing. The nurse must assess for hallucinations that might direct or cause the client to be unsafe or aggressive (eg, suicidal or homicidal themes). It is most therapeutic to ask the client what is being seen, heard, smelled, or felt. Once the specifics of the hallucination are known, the nurse can help the client deal with it. (Option 1) This statement does not help the client now. Later, when the nurse knows exactly what the client is seeing, it might be appropriate to redirect the client to the conversation as a way to ignore the hallucination. (Option 2) Ending the conversation would not be therapeutic as it does not allow the nurse to help the client during the hallucination. (Option 4) This statement is not therapeutic as it addresses the nurse's, not the client's, needs. Educational objective: Communication with a client experiencing a hallucination should first focus on the nature of the hallucination so that the nurse can assess for suicidal or homicidal themes. Test Id: 52095998 Question Id: 30550 (729561) For several months, a client has been unjustifiably accusing the spouse of having affairs. The client comes home from work several times a day to check up on the spouse. Two days ago, the client came home and found the cable TV technician installing new equipment. The client became enraged, accused the spouse of sleeping with the technician, and physically attacked the technician. The police were called, and the client was admitted for psychiatric evaluation. Prior to this admission, the client had been self-sufficient in meeting basic needs and worked and attended church regularly. The nurse recognizes that the admitting history is most indicative of which of the following? Unordered Options Ordered Response 1. Delusional disorder, erotomanic type 2. Delusional disorder, jealous type 3. Schizophrenia with delusions of a persecutory nature 4. Schizophrenia with paranoid features Explanation Delusional disorder is a type of psychosis characterized by isolated delusions that last for at least a month in a client who is otherwise highly functional. The symptoms of other psychotic disorders, such as those associated with schizophrenia (eg, hallucinations, bizarre behavior, disorganized thought processes), are not present. The delusions can be bizarre (out of the realm of possibility) or non-bizarre (possibly true but not). (Option 1) This client's history is not suggestive of an erotomanic type of delusion. (Option 3) This client's delusions are not of a persecutory nature, and there are no symptoms of schizophrenia. (Option 4) This client has otherwise been highly functional and has no symptoms of schizophrenia. Educational objective: Delusional disorder is a type of psychosis characterized by delusions that last at least a month. No symptoms indicative of schizophrenia or another psychotic illness are present, and clients typically are otherwise Test Id: 52095998 Question Id: 31222 (729561) A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide. The client now reports feeling "emotionally upset, alone, and at the end of my rope," due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP). What is the priority nursing diagnosis (ND) at this time? Unordered Options Ordered Response 1. Hopelessness 2. Ineffective coping 3. Risk for infection 4. Risk for suicide Explanation Suicide is the second leading cause of death in people age 15-24. The risk for suicide is increased in individuals with psychiatric disorders, such as depression, and in those who have attempted suicide within the past 2 years. Based on the client's history and statements, the HCP must perform a suicide assessment and take action (ie, psychiatry referral) to provide for the client's safety. This is imperative as the client is prescribed the antidepressant fluoxetine (Prozac) and has had no follow-up with the prescribing HCP. Risk for suicide related to depression is the priority ND. (Option 1) Hopelessness is the belief that a situation or problem is intolerable, inescapable, or unending, and the individual is unable to find a solution. Hopelessness related to inability to find a job, social isolation, lack of medical insurance, and feeling at the "end of my rope" is an appropriate ND for this client, but it is not the priority ND at this time. (Option 2) Ineffective coping is the inability to manage stressors and problems effectively. Depression can affect a client's cognitive ability (eg, poor concentration, lack of judgment) and ability to cope with feelings of despair. Ineffective coping related to inadequate support network, limited socioeconomic resources, and impaired cognitive ability is an appropriate ND for this client, but it is not the priority ND at this time. (Option 3) Risk for infection related to inadequate primary defenses secondary to impaired skin integrity is an appropriate ND for this client, but it is not the priority ND at this time. Educational objective: Risk for suicide related to depression is a priority ND for a client with previous suicide attempts. Test Id: 52095998 Question Id: 30679 (729561) A student nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The student nurse develops a nursing care plan and reviews it with the registered nurse (RN) before meeting with the client. Which of the following nursing actions in the care plan requires an intervention by the RN? Unordered Options Ordered Response 1. Assist the client in identifying the warning signs of a crisis 2. Encourage the client to sign a contract promising not to commit suicide 3. Have the client make a list of people to contact for help and distraction 4. Help the client develop ways of coping with suicidal thoughts Explanation No harm/no suicide contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. However, the practice is controversial. There is no evidence that such contracts reduce suicide, and they may provide a false sense of security. In addition, some clients may feel distrustful of a health care provider who asks a client to sign a contract. If a contract is used, it should be short term with a specific stated time. At the end of the period, a new contract is negotiated. The student nurse must understand that the contract does not guarantee safety and has no legal credibility. A more helpful strategy to support the client with suicidal ideation is safety planning. The plan is created in collaboration with the client and includes the following steps: • Creating a safe home environment – removal of firearms, sharp knives, razor blades, and unnecessary/unused medications • Identifying thoughts, situations, and behaviors that could trigger a suicidal crisis (Option 1) • Identifying ways to cope with suicidal thoughts, such as physical exercise or a distracting activity • Making a list of mental health agencies or hotlines that the client can go to or call when help is needed (Option 3) • Making a list of people who can be contacted for help or distraction (Option 4) Educational objective: An appropriate nursing intervention for assisting a client with suicidal ideation is creation of a safety plan in collaboration with the client. The safety plan should include strategies for making the environment safe, how to identify and cope with signs of an impending crisis, a list of people the client can contact for help or distraction, and the names and phone numbers of facilities and hotlines the client can contact for help. Test Id: 52095998 Question Id: 32123 (729561) The nurse is providing care to a client experiencing posttraumatic stress disorder (PTSD) following a terrorist attack at the client's place of worship. What is the priority nursing action? Unordered Options Ordered Response 1. Acknowledge the client's feelings of anger 2. Assess the client's support system 3. Encourage the client to talk about the trauma 4. Offer the client a PRN sleep medication Explanation The first step toward resolution of PTSD is the client's readiness (ability and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety. The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to discuss the trauma at their own pace. The nurse should also use active listening as a therapeutic approach to build trust and allow clients to vent. This will assist in decreasing their feelings of isolation. The nurse can also guide the client in identifying event details that are most troubling and trigger a sense of loss of control. The effectiveness of the client's coping mechanisms can be identified, and alternate strategies to replace maladaptive ones can be explored. (Option 1) It is important to acknowledge any feelings that the client may have about the trauma; the priority nursing action is to encourage the client to talk about the event. (Option 2) Assessing the client's support system is an appropriate nursing intervention; however, it is not the priority. (Option 4) Sleep aids are used for clients with PTSD and insomnia; however, this is only a temporary solution to one aspect of PTSD clinical presentation. Educational objective: The nurse should encourage clients with PTSD to talk about the experience at their own pace, listen actively to build trust, and allow clients to vent. This will assists in decreasing their feelings of isolation. Test Id: 52095998 Question Id: 30796 (729561) The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior? Unordered Options Ordered Response 1. During 1-2 hours after each meal 2. During every meal 3. During the evening meal 4. During the overnight hours Explanation The eating behavior of a client with bulimia nervosa typically consists of binge eating followed by an inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives. Although it is important to provide one-on-one supervision to a client with bulimia during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting (Option 2). Clients with bulimia nervosa will often go to extreme lengths to engage in purging activity, especially at the beginning of a treatment program, as a way of gaining control. After mealtime, it may be necessary to restrict clients to the dayroom or a specified area with no bathroom privileges for a set period. Clients will also need to be monitored at all times for engaging in excessive exercise. (Option 3) Clients need to be monitored during every meal, not just during the evening meal. (Option 4) Secretive bingeing and purging during the night or before bedtime are not uncommon for a client with bulimia nervosa. However, in a structured inpatient environment, the client would not have access to excessive amounts of food. Educational objective: Clients with bulimia nervosa should be supervised during every meal. However, it is most important to monitor the postprandial activity of these clients to prevent self- induced vomiting as a way to prevent weight gain. Test Id: 52089445 Question Id: 30299 (729561) The nurse is managing the care of a client diagnosed with chronic anxiety. Which behavior demonstrates to the nurse that the client possesses resilience? Unordered Options Ordered Response 1. Avoids anxiety-producing situations 2. Is able to identify anxiety-inducing triggers 3. Practices stress reduction techniques daily 4. Relies on anxiolytic medication to manage symptoms Explanation Resilient people readily deal with the stress they face by using interventions such as deep breathing, meditation, thought interruption, and muscle relaxation. (Option 1) Stress and the anxiety it can cause are unavoidable; taking steps to manage the physical and emotional responses to stress encourages and supports an individual's resilience. (Option 2) Identifying one's anxiety triggers is helpful, but the individual must take action to deal with both the origin and response to the stress. (Option 4) Although anxiolytic therapy may be necessary to manage anxiety, resilience centers on the adaptive techniques an individual uses to address the resulting symptoms. Educational objective: Resilience plays a primary role in an individual's ability to prevent and recover from mental illness and to manage daily stressors. Resilience is strengthened by the practice of appropriate coping skills. Test Id: 52089445 Question Id: 30728 (729561) The emergency department registered nurse is triaging a client for the risk of suicide. The client had thoughts of self-injury yesterday but is not sure today. Which of the following would be considered a known risk factor for suicide in this client? Select all that apply. Unordered Options Ordered Response 1. Constantly hearing voices saying client is worthless 2. Deliberately took an overdose 1 year ago 3. Has a gun at home 4. Married with 3 children 5. Participation in religious activities 6. Unemployed and unable to find a job Explanation The mnemonic SAD PERSONS uses known risk factors and the concept of their accumulation to help predict who is at a higher risk of committing suicide. S Sex (men kill themselves more often than women; women make more attempts) A Age (teenagers/young adults, age >45) D Depression (and hopelessness) P Prior history of suicide attempt E Ethanol and/or drug abuse R Rational thinking loss (hearing voices to harm self) S Support system loss (living alone) O Organized plan; having a method in mind (with lethality and availability) N No significant other S Sickness (terminal illness) This client has a lethal option readily available (Option 3), a history of a prior attempt (Option 2), and loss of rational thinking (Option 1). Unemployed and unskilled individuals are also at risk (Option 6). The client should be triaged as being at high risk and appropriate protective measures instituted. (Options 4 and 5) Social support/family connectedness, pregnancy, parenthood, and religion and participating in religious activities are protective factors against suicide. Educational objective: Elderly white men, severe depression, living alone, prior or family history of suicide attempt, substance abuse, rational thinking loss, organized plan, unemployed or unskilled, and terminal illness are the risk factors for suicide. Social support/family connectedness, pregnancy, parenthood, and religion and participating in religious activities are protective factors against suicide Test Id: 52089445 Question Id: 31024 (729561) A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. The client can state the name and address but has no recollection of the past 2 days. What is the priority nursing action? Unordered Options Ordered Response 1. Assess vital signs 2. Contact family members 3. Encourage the client to recall recent events 4. Perform a mental status assessment Explanation This client is experiencing amnesia of undetermined origin. The cause could stem from a medical condition, substance abuse, traumatic brain injury, cognitive disorder such as dementia, or psychiatric condition such as dissociative fugue. Regardless of the diagnosis, the priority nursing action is to assess the client's physical status. This client has been wandering for 2 days and cannot recall previous locations, arriving at the present location, and the timetable involved. It is highly probable that the client is dehydrated and fatigued. It is most important to assess the client's physical needs and implement interventions to stabilize the physiologic condition before assessing psychosocial status and needs. (Option 2) It is appropriate to contact this client's family members. However, this is not the priority nursing action. (Option 3) This client may never be able to remember the events of the past 2 days. Encouraging a client to remember something when there is no sign of recollection may only increase client frustration. (Option 4) A mental status examination is an important component of the nurse's assessment. However, it is not the priority assessment. Educational objective: Assessment of a client's physiologic status and needs is the priority nursing action when the client is suffering from amnesia with no recollection of where he has been or what he has been doing for a period of time. Interventions need to be implemented to stabilize the client physically before psychosocial needs are addressed. Test Id: 52089445 Question Id: 32016 (729561) The school nurse is called to the classroom to assist with a 7-year-old with attention- deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take? Unordered Options Ordered Response 1. Administer a PRN dose of methylphenidate 2. Ask the child to blow up a balloon 3. Give the child a "time out" in a quiet place 4. Reinforce the consequences of disruptive behaviors Explanation A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however, some children with ADHD behave aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands and challenges. An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow, deep breaths relaxes the body, slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a balloon provides an easy mode of distraction and engages the child in a deep breathing exercise. After the child is calm, the nurse and the child can further discuss the disruptive behavior. Nursing interventions include the following: • Stay calm and remove the child from the source of frustration/anger • Assist the child in calming down with deep breathing exercises • Discuss what precipitated the behavior and why the behavior is wrong • Discuss acceptable ways of expressing anger and frustration • Acknowledge that controlling anger is difficult • Provide rewards for appropriate behavior • Discuss the consequences of inappropriate behavior (Option 1) Methylphenidate is not used on a PRN basis; it is administered daily in 2-3 divided doses (or in sustained release form) 30-45 minutes before meals. (Option 3) Isolating the child is punitive and not therapeutic; instead, remove the child from the source of anger. (Option 4) Reminding the child of the consequences of inappropriate behavior is a valid intervention. However, the best action is to help the child calm down and relax first. Educational objective: The priority intervention for a child with ADHD who is engaging in aggressive behavior is to assist the child in calming down and gaining control. Deep breathing exercises are an easy and efficient approach to help the body and mind slow down and relax. Copyright © UWorld. All rights reserved. Test Id: 52089445 Question Id: 30013 (729561) An adolescent client is brought to the emergency department by the parents after being found in the bathroom making cuts on an arm with a razor blade. There are a few minor cuts in various stages of healing on the client's forearms. Which of the following is the most appropriate statement to make to this client's parents? Unordered Options Ordered Response 1. "Everything is going to be all right." 2. "The cuts on your child's arm are superficial; there is no immediate danger." 3. "You did the right thing by bringing your child here to get help." 4. "You must be very upset after seeing this." Explanation The best therapeutic communication at this time is to inform the parents about the physical condition of their child and reassure them that this client is stable. These are the most immediate concerns of the family. Cutting in adolescence is usually a coping mechanism used when a client is emotionally overwhelmed. Although not technically a suicide attempt, it is a clear indication that this client is unable to process current stressors in life and needs formal assessment by a mental health care provider with experience in adolescent psychiatry. (Option 1) This is a nontherapeutic statement as it implies that there is no cause for concern and provides no specific information about this client's condition. (Option 3) This statement acknowledges that the parents took the appropriate action but provides no information about this client's condition. (Option 4) The nurse can explore the parents' reactions to finding their child cutting after the nurse provides them with information about the child's physical condition. Educational objective: Providing relevant information is a therapeutic communication technique. It helps clients make decisions and feel safer and less anxious. Test Id: 52089445 Question Id: 30572 (729561) A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following? Unordered Options Ordered Response 1. Concrete thinking 2. Loose associations 3. Tangentiality 4. Word salad Explanation Disturbance in logical form of thought is characteristic and one of the positive symptoms of schizophrenia. The client will often have trouble concentrating and maintaining a train of thought. Thought disturbances are often accompanied by a high level of functional impairment, and the client may also be agitated and behave aggressively. Types of impaired thought processes seen in individuals with schizophrenia include the following: • Neologisms – made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox." • Concrete thinking – literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener (Option 1). • Loose associations – rapid shifting from one idea to another, with little or no connection to logic or rationality (Option 2) • Echolalia – repetition of words, usually uttered by someone else • Tangentiality – going from one topic to the next without getting to the point of the original idea or topic (Option 3) • Word salad – a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple." (Option 4) • Clang associations – rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike near the tyke." • Perseveration – repeating the same words or phrases in response to different questions Educational objective: Disturbance in thought process (form of thought) is one of the positive symptoms of schizophrenia. The nurse needs to be able to recognize and identify the various types of thought disturbances experienced by clients with schizophrenia. These include loose associations, neologisms, word salad, echolalia, tangentiality, clang association, and perseveration. Test Id: 52089445 Question Id: 32710 (729561) The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? Unordered Options Ordered Response 1. Constipation and polyuria 2. Increased thirst and dry mucous membranes 3. Leg weakness and soft, flabby muscles 4. Tremors and brisk deep-tendon reflexes Explanation Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: 1. Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority). 2. Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures. (Option 1) Constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect. (Option 2) Increased thirst with dry mucous membranes indicates hypernatremia. (Option 3) Hypokalemia results in muscle weakness/paralysis and soft, flabby muscles. Paralytic ileus (abdominal distension, decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arrhythmias. Educational objective: Clients who abuse alcohol often have low magnesium levels that manifest as ventricular arrhythmias and/or neuromuscular excitability (similar to hypocalcemia), which includes tremors, positive Chvostek and Trousseau signs, hyperactive reflexes, and seizures. Test Id: 52089445 Question Id: 30573 (729561) A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the best response by the nurse? Unordered Options Ordered Response 1. "At the moment, I would worry more about how your sibling is doing." 2. "The odds are about 50-50 that you will come down with the disease as well." 3. "Would you like to talk to a health care provider about this?" 4. "You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia." Explanation The best response should acknowledge the reality of the sibling's concern, provide information, and open the door to further discussion about the development of the disease. Research studies indicate that identical twins have about a 50% chance of developing schizophrenia if one twin develops the disease. This points to a genetic component, but schizophrenia is not entirely a genetic disease. The exact cause is unknown; it most likely results from the interaction and combination of a number of different risk factors. Theories about the cause of schizophrenia include the following: • Biochemical theories - abnormalities affecting the neurotransmitters dopamine, serotonin, norepinephrine, and glutamate • Structural brain abnormalities - reduced size of certain brain areas • Developmental factors - prenatal factors such as faulty neuronal connections • Miscellaneous factors - birth trauma, epilepsy, maternal influenza during pregnancy (Option 1) This response ignores the sibling's concerns and is judgmental. (Option 2) This statement presents the facts in a blunt, non-therapeutic manner; it does not facilitate further discussion about the factors contributing to schizophrenia and/or the sibling's feelings. (Option 3) This dismisses the sibling's concerns and is basically a "non-action" on the part of the nurse Educational objective: Information regarding the potential for development of a serious illness, such as schizophrenia, needs to be provided to clients in a realistic manner that allows for discussion and exploration of the client's feelings. The exact cause of schizophrenia is unknown and is probably a combination of genetic, biochemical, structural, and developmental factors. Test Id: 52089445 Question Id: 30043 (729561) The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply. Unordered Options Ordered Response 1. Bradypnea 2. Diaphoresis 3. Hallucinations 4. Lethargy 5. Tachycardia Last Updated: 1/26/2016 Explanation One of every 6 clients undergoing an emergency surgical procedure will show some signs of alcohol withdrawal during the hospital stay. Screening for heavy use of drugs and alcohol should occur at several points during hospitalization to avoid complications of withdrawal. Delirium tremens and other withdrawal symptoms can be prevented with benzodiazepine administration during hospitalization. The stages of alcohol withdrawal do not always occur as a progressive sequence. (Option 1) Decreased respiratory rate is not a sign of alcohol withdrawal. It is more commonly seen in alcohol or opiate overdose. (Option 4) Clients experiencing alcohol withdrawal symptoms will be agitated and have tremors and hyperreflexia. Educational objective: Alcohol dependency is frequently missed during the admission process. Clients should always be screened for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable. Signs and symptoms of delirium tremens include agitation, fever, tachycardia, hypertension, and diaphoresis. Test Id: 52089445 Question Id: 33383 (729561) A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the best response by the nurse? Unordered Options Ordered Response 1. "I'm sorry. I should have reminded you to sign in." 2. "It is not my fault that you forgot to sign in." 3. "It is your responsibility to sign in when you return from a pass." 4. "You were late coming back from your pass. Is that why you did not sign in?" Explanation Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and justifications. Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and the consequences of not following the rules and regulations of the unit. (Option 1) This is a non-therapeutic response; by apologizing to the client, the nurse is implying that it was the nurse's responsibility to remind the client to sign in. (Option 2) This is a non-therapeutic response as the nurse is on the defensive and not focusing on the client. (Option 4) This is a non-therapeutic response; it is confrontational and assumes the reasoning behind the client's behavior. The response also requires a yes or no answer, which does not facilitate communication. Educational objective: Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. Nursing interventions include setting firm limits and making clients aware of Test Id: 52089445 Question Id: 32050 (729561) A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the best recreational activity for this child? Unordered Options Ordered Response 1. Child's favorite stuffed animal 2. Connect-the-dots puzzle book 3. Putting together a 300-piece jigsaw puzzle 4. Writing in a journal about the hospital stay Explanation Activities for children with intellectual disabilities should be based on the child's developmental age with consideration given to size, coordination, physical fitness, maturity, likes and dislikes, and health status. A child with moderate intellectual disability: • Has academic skills at about the 2nd grade level and may be able to work in a sheltered workshop • Performs self-care activities with some supervision • Participates in simple activities • May have limited speech capabilities Appropriate play activities for this child include simple puzzles, coloring books and crayons, modeling clay, watching cartoons or favorite movies, sticker books, playing with a large ball (eg, inflatable beach ball), simple card and board games, and being read to aloud. (Option 1) Most children would like having their favorite stuffed animal while hospitalized, but it is not the best choice for this child. The toy may be comforting but does not offer the child the opportunity to engage in active play. (Option 3) A 300-piece jigsaw puzzle would be too challenging and frustrating for a child with moderate intellectual disability. (Option 4) Keeping a journal about the hospital stay is a more appropriate activity for a child with a higher level of intellectual development (ie, one who has achieved high school level academic skills). Educational objective: Activities for children with intellectual disabilities should be based on developmental age with consideration given to the child's size, coordination, physical fitness, maturity, likes and dislikes, and health status. Test Id: 52089445 Question Id: 30578 (729561) A client with schizophrenia is hospitalized. After 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing. When first hospitalized, the client refused to leave the room. Now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. What is the most appropriate activity for the client? Unordered Options Ordered Response 1. A board game with a staff member 2. Participation in a group songfest 3. Planning a unit picnic 4. Playing Bingo with other clients Explanation Clients with schizophrenia have difficulty initiating and maintaining social interactions with other people. The nurse can facilitate interpersonal functioning by providing one- on-one interaction in which the client can practice basic social skills in a non-threatening way. Once the client feels more comfortable, the nurse can encourage participation in activities that require some interaction with others. Impaired social interaction is one of the negative symptoms of schizophrenia; others include the following: • Inappropriate, flat, or bland affect, and apathy • Emotional ambivalence, disheveled appearance • Inability to establish and move toward goal accomplishment • Lack of energy, pacing and rocking, odd posturing • Regressive behavior, inability to experience pleasure • Seeming lack of interest in the world and people It is the negative symptoms of schizophrenia that affect a client's ability to establish personal relationships and manage day-to-day social interactions. The positive symptoms of schizophrenia (hallucinations, delusions, thought impairment) often improve with psychotropic medications; negative symptoms tend to persist even with medication. Psychosocial and supportive treatment, including psychotherapy, education, behavioral training, cognitive therapy, and social skills therapy, may be beneficial in improving the quality of life for clients with schizophrenia. (Option 2) The client may not be ready for a group activity. However, due to the limited nature of interaction in a group songfest, it would be appropriate when the client is feeling more comfortable being closer to other people. (Option 3) The client is not ready for this activity. (Option 4) This activity requires interaction with others; the client is not ready for this type of activity. Educational objective: Negative symptoms of schizophrenia include impaired interpersonal functioning and social isolation. Practicing basic social skills in a safe and non-threatening manner, such as a one-on-one activity with the nurse, can help the client with schizophrenia be comfortable with social interactions with others Test Id: 52089445 Question Id: 32618 (729561) An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action? Unordered Options Ordered Response 1. Encouraging frequent fluid intake 2. Keeping the bed elevated with the side rails raised 3. Providing one-on-one supervision 4. Turning lights off in client's room to reduce stimulation Explanation This client is experiencing impairment in cognitive and psychomotor functioning and most likely has delirium brought on by the urinary tract infection. This is not an uncommon occurrence in elderly clients. The client's most immediate needs are safety and prevention of physical injury. Initially, the client should be placed in a room near the nurses' station with one-on-one supervision and frequent reorientation to time, place, and situation. As the condition improves, the client will continue to require frequent observation. (Option 1) It is important for this client to be well hydrated; this can best be accomplished through IV fluids and electrolyte replacement but not by encouraging the client to increase fluid intake. (Option 2) Clients who are agitated often try to get out of bed, even if it means climbing over the side rails. Keeping the bed elevated and side rails raised increases the risk of a fall or other injury as the client attempts to leave the bed. (Option 4) A dark room could worsen the client's confusion, agitation, and disorientation. Lighting helps maintain orientation to the environment; the client's room should be well lit during the day, and dim nightlights should be used at night. Educational objective: Safety is a high priority for clients with delirium. Disorientation, confusion, agitation, and difficulty interpreting reality all increase the risk for physical injury. Close observation, including one-on-one supervision, is essential to ensure client safety. Test Id: 52089445 Question Id: 32121 (729561) The registered nurse is leading a support group for partners of military veterans suffering from posttraumatic stress disorder (PTSD). A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that most individuals with PTSD report which symptoms? Unordered Options Ordered Response 1. Auditory hallucinations, feelings of paranoia, isolation from others 2. Increased anxiety, reliving the event, feeling detached from others 3. Rapidly changing emotions, delusions, lethargy 4. Recurring nightmares, uncontrollable anger, daytime sleepiness Explanation Posttraumatic stress disorder (PTSD) is a reaction to a traumatic or catastrophic event that is typically life-threatening to oneself or others. There are 3 categories of PTSD symptoms: 1. Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis) 2. Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could be trauma reminders, feeling detached and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event 3. Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling jumpy (Option 1) Auditory hallucinations and feelings of paranoia are not characteristic symptoms of PTSD. These are characteristic of schizophrenia. (Option 3) Rapidly changing emotions, delusions, and lethargy are not characteristic symptoms of PTSD. (Option 4) Daytime sleepiness is not characteristic of PTSD. Educational objective: The 3 categories of PTSD symptoms include reexperiencing the traumatic event, avoiding reminders of the trauma, and increased anxiety and emotional arousal. Test Id: 52089445 Question Id: 31404 (729561) The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides. In identifying the characteristics of the typical perpetrator of child abuse, the nurse will include which statements? Select all that apply. Unordered Options Ordered Response 1. Abusers often have a history of substance abuse 2. Abusers often have a history of growing up in an environment of domestic violence 3. Child abusers always present as being agitated or out of control 4. Men are much more likely to abuse children than are women 5. Most child abusers have a diagnosis of a mental illness 6. Teenage parents are particularly vulnerable to abusing their children Explanation Typical characteristics of perpetrators of child abuse include: 1. Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child 2. Confusion between punishment and discipline; having a stern, authoritative approach to discipline 3. Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation (Option 2) 4. Low self-esteem – a sense of incompetence or unworthiness as a parent 5. A history of substance abuse, use of alcohol or drugs at the time the abuse occurs (Option 1) 6. Punitive treatment and/or abuse as a child 7. Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age (Option 6) 8. Resentment or rejection of the child 9. Low tolerance for frustration and poor impulse control 10. Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury (Option 3) Child abusers are not easily identified by appearance; they often appear calm and well in control. (Option 4) Both men and women abuse children at approximately the same rate. Men may be more likely to physically harm a child; women are more likely to neglect a child. (Option 5) Only about 10% of child abusers have a diagnosis of a mental illness. Educational objective: Child abusers often have a history of growing up in an environment of domestic violence. History of substance abuse is also a risk factor. Both men and women abuse children at approximately the same rate. Teenage parents are particularly vulnerable to abusing their children. Test Id: 52089445 Question Id: 31034 (729561) A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse? Unordered Options Ordered Response 1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?" 3. "This has been very overwhelming for you. What are you feeling right now?" 4. "Well, you did find your spouse. You need to focus on helping your spouse get better." Explanation This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident"). When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion. Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness. Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at alleviating the immediate emotional impact of this disruptive crisis event. Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress. (Option 1) Assessing this family's support system is important. However, it is not the priority action at this time. (Option 2) This statement does not address what this client's spouse is experiencing at the moment. At a later time, the nurse can explore the client's history and any events that may have lead to this situation. (Option 4) This response does not address the spouse's concerns. Also, the wording is judgmental and nontherapeutic. Educational objective: Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, and confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions. Test Id: 52089445 Question Id: 33148 (729561) A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan? Unordered Options Ordered Response 1. Assign different staff members to care for the client each day 2. Continue assigning the client's stated preferred nurse to care for the client 3. Frequently reassure the client that all staff members are competent in their jobs 4. Reinforce unit rules and consequences of inappropriate behaviors Explanation Individuals with borderline personality disorder (BPD) live in fear of rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person. An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving. For this client, the nursing care plan must include the assignment of different staff members. This will help diminish the client's dependence on a particular individual and help the client learn to relate to more than one person. (Option 2) Continuing to assign the client's stated preferred nurse will reinforce the manipulative behavior and the need to cling to one person. (Option 3) Simply telling the client about staff competency will not facilitate behavior change. The client is engaging in this behavior as a protection against abandonment. (Option 4) It is important to reinforce unit rules and the consequences of inappropriate behaviors. However, this is not the best action to address the client's attempt to manipulate the staff. Educational objective: Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to rotate staff members assigned to care for the client. Test Id: 52089445 Question Id: 30835 (729561) The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching? Unordered Options Ordered Response 1. "I have to remember to raise my chin slightly upward when I swallow." 2. "I have to remember to swallow 2 times before taking another bite of food." 3. "I should avoid taking over-the-counter cold medications when I'm sick." 4. "I should sit upright for at least 30-40 minutes after I eat." Explanation Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia. Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients (eg, elderly, neurologic dysfunction, decreased cough or gag reflexes, decreased immunity, chronic disease), include the following: • Swallowing 2 times before taking another bite of food. This clears food from the pharynx. • Thickening liquids to assist swallowing • Avoiding over-the-counter cold medications. Antihistamine cold preparation medications also have some anticholinergic properties, such as causing drowsiness, decreasing saliva (xerostomia) production, and making the mouth dry. Saliva is a lubricant, and it helps bind food together to facilitate swallowing. • Sitting upright for at least 30-40 minutes after meals. This uses gravity to move food or fluid through the alimentary tract, decreases gastroesophageal reflux, and helps decrease risk for aspiration. • Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial count before eating because bacteria as well as food can be aspirated. After-meal use removes particles of food that can be aspirated later. • Smoking cessation. Smoking decreases mucociliary clearance and increases bacterial count in the mouth. (Option 1) Positioning the chin slightly downward toward the neck (chin-tuck) when swallowing can be effective in some clients with dysphagia due to its facilitating closure of the epiglottis to help prevent tracheal aspiration. Educational objective: Teaching clients who are susceptible to aspiration about swallowing techniques, positioning, avoidance of over-the-counter cold preparation medications (cause drowsiness and dry mouth), oral care, and smoking cessation can decrease the risk for aspiration pneumonia Test Id: 52089445 Question Id: 30297 (729561) Which client best demonstrates recovery associated with a mental illness? Unordered Options Ordered Response 1. One who demonstrates self-direction and responsibility regarding physical and psychosocial needs 2. One who is receiving holistic care that addresses both physical and psychosocial needs 3. One who lives, works, and is involved with family and friends to the highest level of ability 4. One who, while diagnosed with a mental illness, is able to demonstrate hope for the future Explanation The current conceptualization of recovery is represented by the individual who is functioning in all aspects of living to the highest level of capacity. (Option 1) Demonstrating self-direction and responsibility are 2 of several fundamental components recognized as necessary for recovery. (Option 2) Holistic care is one of several fundamental components recognized as necessary for recovery. (Option 4) The demonstration of hope is one of several fundamental components recognized as necessary for recovery. Educational objective: Among the components necessary for recovery are self-direction and responsibility, holistic care, and hope. When all the components are reasonably represented, recovery is demonstrated by the client's ability to function in all aspects of living to the highest level of capacity. Test Id: 52089445 Question Id: 30297 (729561) Which client best demonstrates recovery associated with a mental illness? Unordered Options Ordered Response 1. One who demonstrates self-direction and responsibility regarding physical and psychosocial needs 2. One who is receiving holistic care that addresses both physical and psychosocial needs 3. One who lives, works, and is involved with family and friends to the highest level of ability 4. One who, while diagnosed with a mental illness, is able to demonstrate hope for the future Explanation The current conceptualization of recovery is represented by the individual who is functioning in all aspects of living to the highest level of capacity. (Option 1) Demonstrating self-direction and responsibility are 2 of several fundamental components recognized as necessary for recovery. (Option 2) Holistic care is one of several fundamental components recognized as necessary for recovery. (Option 4) The demonstration of hope is one of several fundamental components recognized as necessary for recovery. Educational objective: Among the components necessary for recovery are self-direction and responsibility, holistic care, and hope. When all the components are reasonably represented, recovery is demonstrated by the client's ability to function in all aspects of living to the highest level of capacity. Test Id: 52084841 Question Id: 30194 (729561) Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The nurse now evaluates new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The nurse suspects which condition in this client? Unordered Options Ordered Response 1. Amnesia 2. Delirium 3. Dementia 4. Psychosis Explanation Delirium or acute cognitive dysfunction is a syndrome commonly seen in hospitalized clients; it is reversible but difficult to diagnose. Clients may manifest delirium states that can be hypoactive (eg, quiet, disorientation, change in level of consciousness, memory loss), hyperactive (eg, restlessness, agitation, hallucinations, paranoia), or mixed. Manifestations of delirium develop acutely and are difficult to differentiate from those associated with pain, anxiety, and medications. Early diagnosis and treatment are advantageous as delirium is associated with increased mortality (especially in critically ill clients on mechanical ventilation). Delirium is difficult to assess; it is recommended that nurses use a standardized tool (eg, Confusion Assessment Method for the ICU) or checklist (eg, Intensive Care Delirium Screening) for this purpose. (Option 1) Amnesia affects short- and long-term memory loss. It can be intentionally induced by drug use or may occur as a result of trauma or underlying physical/psychological disease processes. Amnesia is not the most likely condition manifested by this client. (Option 3) In contrast to delirium, dementia is gradual in onset and causes an irreversible and progressive cognitive decline. Remote memory is spared initially and there is no impairment of consciousness until the late stages of the disease. (Option 4) Psychosis does not have an acute onset. Clients with this condition are usually oriented but have auditory (not visual) hallucinations. It is not likely in this client. Educational objective: New-onset confusion regarding sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy can be manifestations of delirium in a critically ill client who was previously alert and oriented. Test Id: 52084841 Question Id: 31528 (729561) The office nurse, while reviewing a client's health information, notices that the client has recently started taking St. John's wort for symptoms of depression. What additional information is most important for the nurse to obtain? Unordered Options Ordered Response 1. Ask if the client is currently taking any prescription antidepressant medications 2. Ask if the client has been diagnosed with depression by a mental health care provider (HCP) 3. Ask if the client takes a multivitamin with iron 4. Ask if the client uses tanning beds Explanation St. John's wort is an herbal product commonly used by many clients to treat depression. However, it may interact with medications used to treat depression or other mood disorders, including tricyclic antidepressants, selective serotonin and/or norepinephrine receptor inhibitors (SSRIs/SNRIs), and monoamine oxidase inhibitors (MAOIs). Taking St. John's wort with these medications tends to increase side effects and could potentially lead to a dangerous condition called serotonin syndrome. Serotonin is a chemical produced by the body that is needed for the nerve cells and brain to function. Excessive serotonin causes symptoms that can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever, and seizures). Severe serotonin syndrome can be fatal if it is not treated. (Option 2) The nurse can ask the client if a diagnosis of depression has been made by an HCP, but inquiring about possible medications that can interact with St. John's wort is more important at this time. (Option 3) St. John's wort may interfere with the absorption of iron and other minerals. This is a teaching point, but it is not the highest priority question to ask the client. (Option 4) St. John's wort can cause photosensitivity which could be exacerbated by use of tanning beds. However, this is not the highest priority question to ask the client. Educational objective: St. John's wort interferes with many prescription medications. It is a priority for the nurse to assess for concomitant use of St. John's wort with prescription SSRIs, MAOIs, or tricyclic antidepressants as such combinations Test Id: 52084841 Question Id: 30826 (729561) A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder? Unordered Options Ordered Response 1. Agoraphobia 2. Generalized anxiety disorder 3. Social anxiety disorder 4. Zoophobia Explanation Individuals with agoraphobia have fear and anxiety about being in (or anticipating) certain situations or physical spaces. The fear they experience is out of proportion to any actual danger. These individuals are also highly concerned about having trouble escaping or getting help in the event of a panic attack or panic symptoms. The primary psychological need in agoraphobia is to avoid panic, and individuals with this condition will engage in various behaviors to lessen anxiety and avoid specific situations. In severe agoraphobia, the individual may become homebound, not going to public places for fear of experiencing a panic attack that may cause them to become embarrassed or perform an uncontrollable act. The person with agoraphobia will often feel the need to be accompanied by a relative or friend when facing situations. Agoraphobic individuals most typically fear being in the following situations: • Outside the home alone • In a crowd or standing in line • Traveling in a bus, train, car, ship, or airplane • On a bridge or in a tunnel • Open spaces (eg, parking lots, marketplaces) • Enclosed spaces (eg, theaters, concert halls, stores) (Option 2) In generalized anxiety disorder, the anxiety is evident in various situations and can impact all areas of an individual's life (eg, workplace, family/relationships, general well-being). (Option 3) In social anxiety disorder, individuals fear being scrutinized, observed, or embarrassed in social or performance settings (eg, public speaking, eating in public). (Option 4) Zoophobia is fear of animals. Educational objective: Agoraphobia is characterized by intense anxiety about being in a situation from which there may be difficulty escaping in the event of a panic attack. A person with agoraphobia may avoid open spaces, closed spaces, riding in public or private transportation, going outside the home, bridges/tunnels, and crowds. Test Id: 52084841 Question Id: 30685 (729561) A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client? Unordered Options Ordered Response 1. Assess the client's risk for another suicide attempt 2. Encourage the client to express current feelings about the medical diagnosis 3. Place the client in a private room near the nurses' station 4. Provide continuous one-to-one observation with the client Explanation This client has made a suicide attempt and is at high risk for additional suicidal behavior. Therefore, the client's priority need is for safety. The best nursing action is to provide one-on-one contact with the client to ensure constant observation and that the client does not engage in self-harm. The presence of the nurse will also convey a sense of acceptance, concern, and caring and provide an opportunity for the client to express feelings about the current situation. Additional nursing interventions for the client at high risk for suicide include the following: • Removing sharp and other potentially harmful objects (eg, belts, metal eating utensils, ties, glass items) from the client's environment • Making sure the client swallows medications • Supervising the client during meals • Placing the client in a semiprivate room near the nurses' station (to reduce social isolation and allow easier access to the client) • Making rounds at irregular intervals for the client who does not need constant observation, as well as at shift changes and when staff is unusually busy • Encouraging the client to express feelings, especially anger • Having an open and honest conversation with the client about changing suicide risk (Option 1) This is an appropriate nursing action but not the highest priority action. (Option 2) This is an appropriate nursing action but not the priority action. (Option 3) A client at risk for suicide should be placed in a semiprivate room. Educational objective: The priority nursing action for a client who has made a recent suicide attempt is to ensure the client's safety. The best approach is to provide one-on-one contact and constant observation. Test Id: 52084841 Question Id: 30714 (729561) A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms? Unordered Options Ordered Response 1. Denial and projection 2. Rationalization and depression 3. Regression and displacement 4. Sublimation and reaction formation Explanation Defense mechanisms are strategies or responses, usually unconscious, used by individuals to distance themselves from a full awareness of unpleasant thoughts, internal conflicts, and external stresses. Defense mechanisms protect the ego from threatening thoughts and anxiety. Denial is the refusal to accept the reality of threatening situations, or painful thoughts, feelings, or events. It is the most frequent defense mechanism used by clients with alcoholism; the client may deny that drinking is a significant problem and that any issues or problems can be handled alone. This client is also using projection by saying that the spouse should be hospitalized; projection involves placing one's own thoughts, feelings, or impulses onto someone else. (Options 2, 3, and 4) Rationalization, regression, displacement, sublimation, and reaction formation are not the primary defense mechanisms used by the client. This client displays no symptoms of depression. Educational objective: The most common defense mechanism used by persons with alcoholism is denial, the refusal to accept the reality of threatening situations, or painful thoughts, feelings, or events. Projection involves placing one's own thoughts, feelings, or impulses onto someone else. Test Id: 52084841 Question Id: 33460 (729561) The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. What is the best explanation for these clinical characteristics? Unordered Options Ordered Response 1. The client is attempting to maintain self-esteem 2. The client is experiencing delusions of grandeur 3. The client is feeling threatened 4. The client is trying to prevent a panic attack Explanation A client with narcissistic personality disorder (NPD) exhibits a recurrent pattern of grandiosity, need for admiration, and lack of empathy. Clients with NPD may project a picture of superiority, uniqueness, and independence that hides their true sense of emptiness. From a psychodynamic perspective, individuals with NPD have a fragile and damaged ego resulting from a childhood environment that fostered a sense of inferiority, poor self- esteem, and severe self-criticism. Narcissistic characteristics develop as a way to regulate self-esteem and protect the ego from further psychic injury. (Option 2) Delusions of grandeur are experienced by clients with a psychotic disorder; NPD is a personality disorder. (Option 3) Clients with NPD may feel threatened if criticized or if others do not meet their emotional demands. However, this is not the best explanation of the clinical characteristics associated with NPD. (Option 4) Panic attacks are characteristic of clients with an anxiety disorder, not NPD. Educational objective: The clinical characteristics of narcissistic personality disorder can best be explained as an attempt to maintain a fragile self-esteem that was damaged during childhood due to an environment that was highly critical, demanding, and fostered a sense of inferiority. Test Id: 52084841 Question Id: 30620 (729561) A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly." During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the best response by the nurse? Unordered Options Ordered Response 1. "How could your fiancé be wonderful after saying those things to you?" 2. "I think you are better off without your fiancé." 3. "Maybe the breakup was for the best." 4. "Tell me how you felt when your fiancé broke up with you." Explanation Clients with major depressive disorder experience feelings of worthlessness, low self- esteem, hopelessness, and guilt. Anger is turned inward and they may misinterpret reality and have an idealistic perception of a lost entity. They may blame themselves for what has happened, such as losing a loved one or being fired from a job. The nurse needs to remain nonjudgmental, listen to the client attentively, and convey a caring and accepting attitude to promote trust. Allowing the client to identify and verbalize feelings, including anger, in a comfortable environment will help the client see the situation in a more realistic way and come to terms with what has happened. (Option 1) The nurse is challenging the client's perception of reality; this will increase the client's anxiety and inhibit further communication. (Option 2) The nurse is offering an opinion and challenging the client's statement; this is not a therapeutic response. (Option 3) The nurse is offering an opinion; it is not a therapeutic response. Educational objective: Nursing interventions for a depressed client who expresses feelings of worthlessness and guilt and has a distorted sense of reality include listening attentively, encouraging the client to verbalize feelings about what has happened, and helping the client view the situation in a more realistic way. Test Id: 52084841 Question Id: 32107 (729561) The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessments would support this diagnosis? Select all that apply. Unordered Options Ordered Response 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood Explanation Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). There are 3 categories of PTSD symptoms: 1. Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (eg, rapid, pounding heart; gastrointestinal distress; diaphoresis) (Option 4) 2. Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event (Option 2) 3. Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of rage, persistent anger and/or fear, difficulty concentrating, hypervigilance, and exaggerated startle response (Options 1 and 5) (Option 3) Persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep. Educational objective: A person suffering from post-traumatic stress disorder experiences 3 categories of symptoms: reexperiencing the traumatic event, avoiding reminders of the trauma, and hyperarousal. Test Id: 52084841 Question Id: 30065 (729561) The nurse is educating a client in preparation for discharge from the hospital when the client breaks down crying, saying that the health care provider thinks she is crazy because he diagnosed her with a functional disorder. Which statement would be the best reply to this client? Unordered Options Ordered Response 1. "Functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand." 2. "I am very sorry to hear this, but are you sure that’s what he meant?" 3. "The health care provider does not know what he’s talking about. I’ll give you the information my health care provider used." 4. "Why do you think he said that?" Explanation Educate clients when there is a clear medical misunderstanding. Epilepsy and migraines are examples of functional disorders described for centuries before medical science allowed for a provable diagnosis or development of an effective treatment. (Option 2) Expressing an apology is acceptable if it is genuine, but questioning the client using words that could be construed as patronizing is not the best method. (Option 3) Casual accusations of incompetence regarding other personnel are unprofessional and can result in legal consequences. A nurse who directly observes a medical error or impairment of a colleague must report the facts to the nursing administration for formal investigation. (Option 4) Exploring the issue is an unnecessary step when education could quickly resolve the problem. Educational objective: Functional disorders are currently undiagnosable medical issues and should not be confused with psychosomatic illness, attention-seeking behavior, or malingering. Test Id: 52084841 Question Id: 31960 (729561) A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? Select all that apply. Unordered Options Ordered Response 1. Explore the meaning behind the client's delusions 2. Focus on reality and verbally reinforce it 3. Focus on the client's feelings secondary to the delusions 4. Gently confront the client about the false beliefs 5. Present logical explanations to discredit the delusions Explanation Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to understand them and the nurse-client relationship grows (Option 3). Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions (Option 2). For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real." (Option 1) Attempting to explore the meaning behind a delusion will encourage the client to focus/think more on this delusion. (Option 4) Confronting the client about the delusion is not therapeutic because arguing will not eradicate the delusion. It also hinders the development of a trusting nurse-client relationship. (Option 5) Clients believe that their delusions are real despite proof otherwise. Presenting logical explanations to discredit the delusions will not help. Educational objective: When communicating with a delusional client, the nurse must focus on the client's feelings and reinforce reality rather than argue or present evidence that the delusion is false or irrational. Test Id: 52084841 Question Id: 30630 (729561) A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks? Unordered Options Ordered Response 1. Daily sleep disturbance or significant weight loss 2. Decreased ability to think or low energy 3. Depressed mood or loss of interest or pleasure 4. Thoughts of worthlessness or recurrent thoughts of death Explanation Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client. For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2 weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure. (Option 1) Daily sleep disturbance or significant weight loss is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 2) Decreased ability to think or low energy is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 4) Thoughts of worthlessness or recurrent thoughts of death are symptoms of depressive disorders; these are not key clinical features necessary for diagnosis. Educational objective: The 2 key clinical features of major depressive disorder (unipolar depression) are depressed mood and loss of interest or pleasure. One of these symptoms must be present daily for at least 2 weeks for the diagnosis of major depressive disorder to be made. Test Id: 52084841 Question Id: 32827 (729561) The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply. Unordered Options Ordered Response 1. Assisting clients with bathing and hair care 2. Evaluating safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime Explanation Many clients with advanced Alzheimer disease reside in long-term care centers; therefore, most routine care activities can be delegated to the licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). The role of the LPN includes: • Administration of enteral feedings (if prescribed) • Administration of medications • Monitoring for safety hazards • Monitoring for behavioral changes The role of UAP includes: • Assisting with activities of daily living (eg, toileting, bathing, skin care, oral care, personal hygiene) (Option 1) • Assisting with feeding • Reporting changes in ability to eat or difficulty swallowing (Option 5) • Reporting changes in behavior • Placing bed alarms to reduce risk of falls (Option 4) (Option 2) UAP may be directed by a nurse to remove or alter safety hazards in a client's room, but the nurse retains the responsibility of evaluating the environment. (Option 3) The UAP may report changes in client behavior to the nurse. The LPN can monitor for behavioral changes, and the RN can develop strategies to address difficult behavior. Educational objective: While caring for a client with Alzheimer disease, the licensed practical nurse is responsible for administration of medications and enteral feedings (if prescribed) and monitoring for safety hazards and behavioral changes. The role of unlicensed assistive personnel involves helping with activities of daily living and reporting changes in the client. Copyright © UWorld. All rights reserved. Test Id: 52084841 Question Id: 30551 (729561) A college student finds a roommate mumbling and huddling in the corner of the room. The student brings the roommate to the emergency department, where the roommate is tentatively diagnosed with schizophrenia. The treatment plan includes hospitalization on the acute psychiatric unit and initiation of anti-psychotropic medication therapy. The client refuses to be admitted. Which of the following statements about hospital admission is true for this client? Unordered Options Ordered Response 1. If the client refuses to cooperate with the treatment plan, the client can be involuntarily committed. 2. If the treatment team determines the client poses danger to self or others, the client can be involuntarily committed. 3. The client can be involuntarily committed for observation and treatment if the roommate can provide consent. 4. The diagnosis of schizophrenia alone justifies the need for involuntary commitment. Explanation Clients have the right to refuse hospital admission and treatment under the Fourteenth Amendment to the United States Constitution, which guarantees protection against loss of liberty. However, all states have laws and procedures for involuntary commitment that require clients to receive inpatient treatment for a psychiatric disorder against their will. The legal criteria for involuntary commitment include the following: • The individual appears to be an imminent danger to self or others and • Grave disability – as a result of a mental illness, the person is unable to adequately care for basic needs, including food, clothing, shelter, medical care, and personal safety Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner. Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that judgment and insight in deciding to refuse treatment are markedly impaired. (Option 1) Refusing to cooperate with the treatment plan is not a criterion for involuntary commitment. Clients have the right to refuse treatment. (Option 3) A roommate is not an appropriate surrogate decision maker to give consent. The spouse, children, or parents are usually contacted when clients are not able to give consent. (Option 4) The diagnosis of a mental illness alone does not justify the need for involuntary commitment. Educational objective: Clients with a mental illness have the right to refuse treatment, including inpatient hospitalization. Clients can be involuntarily committed for psychiatric treatment if they pose an imminent danger to themselves or others or if they are gravely disabled and unable to meet their own basic needs. Test Id: 52084841 Question Id: 32249 (729561) The nurse on the mental health unit received report on 4 clients. Which client should the nurse see first? Unordered Options Ordered Response 1. Client diagnosed with major depressive disorder who has consumed no food from the past 3 meal trays 2. Client diagnosed with post-traumatic stress disorder who reports an anxiety level of 8/10 and is pacing in the room 3. Client newly admitted with bipolar mania who reports sleeping only 4 hours last night 4. Client newly admitted with obsessive-compulsive disorder who has spent the last hour counting socks Explanation Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). Symptoms of PTSD include re-experiencing the traumatic event via flashbacks, nightmares, and feelings of distress in reaction to reminders; avoiding reminders of the trauma (eg, places, activities, thoughts, other triggers); and increased anxiety and emotional arousal (eg, insomnia, hypervigilance, outbursts of rage, irritability). Clients with an anxiety level of 8/10 and pacing behavior are demonstrating distress and require immediate attention as they might harm themselves or others. (Option 1) Clients with major depressive disorder frequently demonstrate loss of appetite, weight loss, and insomnia (typical depression). Some with atypical depression will experience increased appetite, weight gain, and hypersomnia. This client's lack of appetite needs to be addressed but is not the priority at this time. (Option 3) Clients experiencing acute mania have a decreased need for sleep and boundless energy; they often do not sleep for days. This is an expected behavior in a client newly admitted with a manic episode. As the client's manic episode is resolved via medications and therapy, sleep patterns will improve. (Option 4) Clients with obsessive-compulsive disorder perform compulsive behaviors (rituals) to decrease their level of anxiety. When newly admitted, the client should be given time to perform the rituals to avoid causing panic anxiety. Treatment will focus on assisting the client to develop better coping behaviors and gradually reduce the time spent on the ritualistic behavior. Educational objective: Clients with post-traumatic stress disorder have periods of extreme anxiety and emotional arousal during which they can be a danger to themselves or others. Test Id: 52084841 Question Id: 30332 (729561) An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful? Unordered Options Ordered Response 1. "I am busy right now but can stay for a few minutes." 2. "I can call the clergy to come sit with you." 3. "I can stay and sit with you if you would like." 4. "I don't think I should interrupt your family time." Explanation During the end-of-life process the client's family members may be frightened, sad, confused, or concerned, and may ask staff questions about belief systems or the death process. Sometimes clients or family members simply want the nurse to sit with them and provide reassurance that their loved ones are worthy of time and attention. The most therapeutic response by the nurse is to sit with the client and/or family for at least a few minutes. (Option 1) Telling family members that a nurse is busy is not a helpful response. They may feel guilty about asking for the nurse's time and attention. If needed, the nurse can ask coworkers to help with other assigned clients. (Option 2) Although calling clergy members may be appropriate, it may take several hours for them to arrive. This is not the most helpful response. (Option 4) Family members who ask the nurse to stay for a few minutes may have questions or need emotional support. In such cases, it is not helpful for the nurse to decline. Educational objective: During the end-of-life process, the client and family members typically go through several emotional stages, each requiring therapeutic communication techniques by the nurse. The nurse can help the client and family by providing a few minutes of time and attention. The nurse should validate the family's needs by providing emotional support. Copyright © UWorld. All rights reserved. Test Id: 52084841 Question Id: 33548 (729561) Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? Unordered Options Ordered Response 1. "I really appreciate all the time you have spent trying to help me." 2. "I think I really messed up at work today." 3. "My mother could not drive me here today, so I took the bus." 4. "When my parents go away on vacation, I'm planning to stay with my cousin." Explanation Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include: • Difficulty in making day-to-day decisions • An excessive need for advice, reassurance, and nurturance from others • Lack of self-confidence - afraid to do things on one's own • Afraid of confrontation or expressing disagreement with others • Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward a therapeutic outcome. (Option 1) Clients with dependent personality disorder will often express appreciation or make flattering comments to the nurse/therapist to gain approval. (Option 2) Clients with dependent personality disorder lack confidence in their own abilities; this client is expressing self-doubt and is not showing evidence of improvement. (Option 4) The need to stay with someone while the client's parents are away is not evidence of progress toward a therapeutic outcome; the client cannot tolerate being alone. Educational objective: Clients with dependent personality disorder have an extreme need to be taken care of by another person, cannot make decisions on their own, and have intense fear of separation and being left alone. The ability to make a decision and act on one's own would indicate progress toward a therapeutic outcome. Test Id: 52084841 Question Id: 30537 (729561) A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis? Unordered Options Ordered Response 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity Explanation A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: • Immobility—the client remains in a fixed stupor or position for long periods o Refuses to move about or engage in activities of daily living o May have brief spurts of excitement or hyperactivity • Remaining mute • Bizarre postures—the client holds the body rigidly in one position • Extreme negativism—the client resists instructions or attempts to be moved • Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person • Staring • Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care. (Option 1) Impaired social interaction is also an appropriate nursing diagnosis in a client with catatonic schizophrenia. However, it is not a priority, especially during the early phases of the disease. (Option 2) The client's mutism makes the diagnosis of impaired verbal communication appropriate, and the nurse should gently encourage this client to talk without undue expectations or pressure. This is not the priority nursing diagnosis. (Option 4) If this client is in a bizarre or fixed posture, there may be a risk for decreased circulation and pressure ulcers. The nurse needs to encourage ambulation and/or provide range-of-motion exercises. Educational objective: Clients with catatonic schizophrenia are unable to meet their own needs for fluids, food, movement, and elimination and need assistance in performing basic activities of daily living. However, a priority diagnosis is deficient fluid volume. Test Id: 52084841 Question Id: 33382 (729561) The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self-inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the best response by the nurse? Unordered Options Ordered Response 1. "Are you still going to take your business trip?" 2. "It sounds like you are having a difficult time coping with your partner's behavior." 3. "Your partner is most likely doing it for attention, so it's best to just ignore it." 4. "Your partner needs to be seen in the clinic today." Explanation Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a suicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior. (Options 1 and 3) The priority is for the client to be evaluated at the clinic due to the diagnosis and risk for suicide. The partner's response to the client's behavior can be discussed later. (Option 2) This is not the priority response; it focuses on the partner's needs rather than the client's. Educational objective: Clients with borderline personality disorder are at very high risk for suicide. Suicidal gestures and attempts must be taken seriously and evaluated for suicidal intent. Copyright © UWorld. All rights reserved [Show More]

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